Carrie Hoke, Associate Member, Immigration and Human Rights Law Review
I. Introduction
The H-1B visa program, formally established by the Immigration Act of 1990, was created to assist employers who sought to hire noncitizens for specialty occupations that require highly specialized knowledge.[1] The H-1B program provides employers with a tool to fill employment gaps that cannot otherwise be met by U.S. citizens by allowing qualified individuals to gain temporary employment.[2] However, the Trump Administration’s recent imposition of a $100,000 fee for each H-1B petition has made the process far more expensive for employers.[3] Although the Administration claims this payment is necessary to secure national interests and prevent employers from abusing the program, the fee poses an immediate and alarming threat to an already fragile healthcare system, particularly in poor and rural communities.[4]
II. Background
The H-1B visa program is rooted in long-standing legislation designed to admit highly skilled workers to address U.S. employment gaps.[5] The healthcare industry depends heavily on the H-1B program to fill gaps in essential medical positions.[6] In 2024, foreign-trained H-1B visa holders accounted for 23% of licensed physicians in the United States.[7] Of these physicians, roughly 64% practiced in Medically Underserved Areas or Health Professional Shortage Areas, with nearly half of them working in rural communities.[8] In practice, this new and highly restrictive fee poses an immediate threat to an already overburdened healthcare system, a threat whose damage will only be compounded in poor and rural communities that rely on international H-1B visa medical professionals to maintain access to affordable healthcare.[9]
A. History of the H-1B Visa
On October 3, 1965, President Lyndon B. Johnson signed the Immigration and Nationality Act of 1965 (“INA”) into law.[10] The INA abolished the previous quota-based system used to regulation immigration and prioritized admitting highly skilled workers who could contribute to the United States’ growth, setting forth the foundation of the H-1B program.[11]
The Immigration Act of 1990 formally established the current H-1B visa program, which is designed to assist employers who seek to hire foreign individuals in specialty occupations or as fashion models of distinguished merit and ability.[12] To qualify for a specialty occupation, applicants must have highly specialized knowledge in a particular field and attain, at minimum, a bachelor’s degree in a directly related field-specific specialty.[13] The goal of the H-1B program is to provide an additional tool to employers who cannot otherwise fill employment gaps derived from the U.S. workforce.[14] H-1B visas allow qualified individuals who would otherwise not be eligible to gain employment in the U.S. to seek temporary employment while establishing safeguards to ensure U.S. workers are not adversely affected.[15] However, the Trump Administration’s recent changes to the H-1B visa program have made the process of obtaining such a visa far more difficult and costly, leading employers—especially in the healthcare industry—to struggle with filling employment gaps and reducing the effectiveness of the H-1B program.[16]
B. Implementation of H-1B Visa Fee
On September 19, 2025, President Trump issued a Proclamation modifying the parameters of the H-1B visa.[17] The Proclamation highlighted the alleged shortcomings of the H-1B visa program in failing to follow “America First” policies on which many of the current administration’s policy decisions are based.[18] As a result of the Proclamation’s modifications, employers are now required to supplement H-1B petitions with a payment of $100,000 per application.[19] The Administration asserts this payment is necessary to prevent employers from relying on international workers to reduce expenses and to protect national security interests. However, the Department of Homeland Security (”DHS”) Secretary may provide fee exemptions in particular circumstances.[20]
Exemptions from the required H-1B petition supplemental payment may be provided to noncitizen individuals or groups working for a company or in an industry if the DHS Secretary determines H-1B employment for that company or industry would benefit the national interest and pose no threat to the security or welfare of the nation.[21] The United States Citizenship and Immigration Services (”USCIS”) provides a more restrictive definition of the exemption, requiring the Secretary to establish the following factors on a case-by-case basis: (1) the noncitizen’s presence in the U.S. is in the national interest; (2) there is no American worker who can fill the role; (3) the noncitizen is not a threat to national security or welfare; and (4) requiring payment of the fee would significantly undermine national interests.[22] Industry-wide exemptions for healthcare workers are crucial, as medical organizations across the nation are already facing significant shortages of qualified healthcare workers who ensure access to quality healthcare.[23]
C. Shortcomings of U.S. Medical Education
The U.S. healthcare workforce faces immense strain due to a growing aging population and a lack of young healthcare professionals available to provide necessary care.[24] The National Center for Health Workforce Analysis (”HRSA”) predicted a shortage of more than 187,000 full-time equivalent physicians by 2027. [25] In large part, the growing shortage of American physicians is a result of the Balanced Budget Act of 1997, which mandated residency caps restricting the number of medical school graduates who can enter Medicare-funded residency programs.[26] Although this Act originally intended to curb Medicare funding, these caps led to an unintended bottleneck of medical graduates entering the workforce.[27] This issue will likely be exacerbated as incoming loan caps will further limit who can afford to attend medical school.[28] Hospitals and medical organizations across the nation are attempting to remedy the issue through utilization of the H-1B program.[29]
American hospitals are experiencing physician shortages across the nation, prompting many to recruit international healthcare workers through the H-1B program to fill the gaps.[30] However, the issue of understaffed medical facilities is now exacerbated by the new $100,000 required supplemental payment.[31] The American Medical Association (“AMA“), along with 56 other medical organizations, directed a letter to the Secretary of the DHS, urging the department to allow exemptions for medical personnel to mitigate the potential risks to the healthcare profession and underserved American communities.[32]
III. Discussion
The imposition of a $100,000 supplemental fee for H-1B visa petitions poses an immediate and alarming threat to the already fragile healthcare system, particularly in poor and underserved communities.[33] This section analyzes the consequences of this newly imposed barrier, calls for clarification of the national interest exemption, and proposes solutions necessary to protect U.S. communities and healthcare infrastructure.
A. Effect on Underserved Communities
H-1B medical professionals disproportionately serve the nation’s poor and rural populations.[34] However, the restrictive cost of the new fee has already forced hospitals to halt H-1B recruitment efforts.[35] Frederick Health in Maryland reported that, while initially wanting to sponsor up to 45 nurses on H-1B visas, it could no longer attempt to fill the physician gaps for even one individual, asserting that the expense was unaffordable.[36] The American Hospital Association (”AHA”) has warned that an increase in petition fees will likely prevent hospitals, particularly small and midsize facilities, from hiring necessary health care staff, thereby reducing the number and quality of their available services.[37]
Foreign-trained physicians employed through H-1B visas are critical to combatting physician shortages, particularly in poor and vulnerable areas that are often neglected by U.S. graduates.[38] Rural areas are already at a steep disadvantage in receiving access to adequate healthcare and retaining U.S. medical staff, as in 2019, rural and nonmetropolitan areas had only 13 physicians per 10,000 people compared to 33 per 10,000 in metropolitan areas.[39] In 2021, approximately 64 percent of foreign-trained medical professionals were practicing in “Medically Underserved Areas” or “Health Professional Shortage Areas,” with 46 percent of these professionals working in rural areas.[40] Additionally, studies show a geographical overlap between areas with a higher concentration of H-1B physicians and those with lower physician density.[41] This geographic concentration of H-1B physicians in underserved areas suggests that greater obstacles in the visa process will directly influence the levels of harm faced by these communities.
The sudden financial burden and uncertainty associated with the new H-1B restrictions risks deterring international medical professionals from choosing to pursue employment in U.S. healthcare facilities.[42] As a result, those affected may now choose to take their skills to other countries with easier or cheaper visa pathways, rather than subjecting themselves to a lengthy and strenuous recruitment process in the United States.[43]
B. Proposed Solutions
The AMA’s letter to the DHS Secretary highlights the significant ambiguity surrounding the national interest exemption to the new H-1B petition fee.[44] The AMA urges DHS to clarify the scope of this exemption and confirm that all physicians qualify as critical to the national interest and are therefore exempt from the fee.[45] To bolster support for this movement, the AMA has launched a grassroots engagement campaign which aims to gather support for congressional clarification of the exemption and to ultimately secure a broad exemption for physicians.[46]
The current Administration must now provide guidance on whether exemptions may apply on an industry-wide basis. Establishing an industry-wide exemption for physicians would promote efficiency by preventing unnecessary and excessive government oversight and reducing government costs. Without such clarification of the rule, hospitals, particularly those in poor and rural areas, risk being unable to recruit essential healthcare workers, leaving many U.S. residents without adequate access to medical care.[47]
Medical organizations across the United States are attempting to remedy the shrinking healthcare workforce in other ways. The AHA has been in support of bills that would increase the number of Medicare-funded residency positions to allow for expanded training capacity.[48] Additionally, the AHA supports adoption of the Healthcare Workforce Resilience Act, which would recapture up to 40,000 unused immigrant visas for physicians and nurses.[49] However, these solutions have been slow to progress and will not be quick to pass, which will lead to increased strain on poor and rural communities that are drastically affected by poorly staffed medical facilities.
Medical organizations recognize securing exemptions for medical professionals as a temporary, but necessary, resolution to the broader issue of a shrinking American medical workforce.[50] While the AHA recognizes a need for long-term changes, allowing H-1B exemptions for physicians is a necessary measure to support U.S. healthcare and prevent the exacerbation of existing physician shortages.[51]
IV. Conclusion
The Trump Administration’s imposition of a $100,000 supplemental fee on H-1B visa petitions poses an immediate and serious threat to an already strained healthcare system.[52] The additional cost places H-1B hiring out of reach for many hospitals, disproportionately affecting small and midsize facilities, and forcing many to suspend hiring efforts.[53] The heightened financial burden and uncertainty risk discouraging qualified international medical professionals from bringing their skills to the United States, pushing them toward more accessible or affordable visa pathways elsewhere. Although the Administration’s order provides exemptions related to the national interest, the criteria are far too narrow and insufficiently defined.[54] While long-term resolutions are in motion to resolve the healthcare staffing crisis, they will not offer near-term relief. Accordingly, to prevent worsening physician shortages and stabilize the U.S. healthcare system, DHS must clarify and adopt an industry-wide national interest exemption. Physicians and other healthcare professionals are crucial to national security and to the very purpose of the H-1B program in filling critical employment gaps and must therefore be categorically exempt from the supplemental fee.
[1] Immigration Act of 1990, Pub. L. No. 101-649, 104 Stat. 4978.
[2] Id.
[3] Restriction on Entry of Certain Nonimmigrant Workers, 90 Fed. Reg. 46027 (Sept. 24, 2025) [hereinafter Restriction].
[4] Id.
[5] Immigration Act of 1990, supra note 1.
[6] Letter from Am. Med. Ass’n to Hon. Kristi Noem, Sec’y, U.S. Dept. of Homeland Sec., (Sept. 25, 2025) (on file with author) [hereinafter AMA Letter].
[7] Id.
[8] Id.
[9] Letter from Richard J. Pollack, President & Chief Exec. Officer, Am. Hosp. Ass’n, to Hon. Kristi Noem, Sec’y, U.S.
Dept. of Homeland Sec., (Sept. 29, 2025) (on file with author) [hereinafter AHA Letter].
[10] Immigration and Nationality Act of 1965, Pub. L. 89-236, 79 Stat. 911.
[11] Immigration and Nationality Act, LBJ Library, https://www.lbjlibrary.org/news-and-press/media-kits/immigration-and-nationality-act [https://perma.cc/P7DE-HZC2] (last visited Dec. 3, 2025).
[12] Immigration Act of 1990, supra note 1.
[13] H-1B Specialty Occupations, U.S. Citizenship & Immigr. Serv.,
https://www.uscis.gov/working-in-the-united-states/h-1b-specialty-occupations [https://perma.cc/J8F7-DYUA] (last updated Oct. 20, 2025); H-1B Program, U.S. Dep’t of Lab. Wage & Hour Div., https://www.dol.gov/agencies/whd/immigration/h1b [https://perma.cc/83CU-VQ52] (last visited Dec. 3, 2025).
[14] Id.
[15] Safeguards include those built into the “specialty occupations” definition, which requires individuals have highly specialized knowledge and a bachelor’s degree in a directly related field. Additionally, employers must pay H-1B users a wage no less than other similarly qualified workers or the prevailing wage in a particular geographic area, whichever is greater. See H-1B Specialty Occupations, supra note 13.
[16] Restriction, supra note 3.
[17] Id.
[18] Id.
[19] Id.
[20] Id.
[21] Id.
[22] As of now, the DHS has issued no company or industry-wide exemptions for the H-1B petition fee. See H-1B Specialty Occupations, supra note 13.
[23] AHA Letter, supra note 9.
[24] AMA Letter, supra note 6.
[25] State of the U.S. Health Care Workforce, Nat’l Ctr. for Health Workforce Analysis (Nov. 2024), https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/state-of-the-health-workforce-report-2024.pdf [https://perma.cc/V7RK-YQJ7].
[26] Matthew Blakey, Washington created the doctor shortage – here’s how to end it, The Hill (Oct. 12, 2025), https://thehill.com/opinion/healthcare/5550556-residency-cap-doctor-shortage/#:~:text=In%20the%20Balanced%20Budget%20Act,one%20of%20its%20major%20expenses [https://perma.cc/TAN4-M5BS].
[27] Id.
[28] Alisa Pierce, Federal Loan Changes Could Exacerbate Medical Students’ Financial Challenges, Tex. Med. Ass’n
(Nov. 4, 2025), https://www.texmed.org/TexasMedicineDetail.aspx?id=66900 [https://perma.cc/ALT4-AECJ].
[29] Natalie Brand, Hospitals hope for exemption from Trump administration’s new $100,000 H-1B visa fee: “We cannot afford that”, CBS News (Oct. 29, 2025), https://www.cbsnews.com/news/hospitals-trump-h1b-visa-fees/
[https://perma.cc/3DQK-AH32].
[30] Id.
[31] Id.
[32] AMA Letter, supra note 6.
[33] Rick Pollack, Exempting Health Care Personnel from H-1B Visa Fees Is Good for Patients and Providers, Am. Hosp. Ass’n (Oct. 17, 2025), https://www.aha.org/news/perspective/2025-10-17-exempting-health-care-personnel-h-1b-visa-fees-good-patients-and-providers [https://perma.cc/A77B-FVPN].
[34] AHA Letter, supra note 9; AMA Letter, supra note 6.
[35] Brand, supra note 29.
[36] Id.
[37] Pollack, supra note 33.
[38] AMA Letter, supra note 6.
[39] Maggie Shaw, 5 Specialty Care Shortages in Rural Communities, Am. J. Managed Care, (Sep. 13, 2024), https://www.ajmc.com/view/5-specialty-care-shortages-in-rural-communities [https://perma.cc/W4VY-GGP3].
[40]AMA Letter, supra note 6.
[41] Id.
[42] AHA Letter, supra note 9.
[43] Id.
[44] AMA Letter, supra note 6.
[45] Leslie Dellon, USCIS Implements the H-1B Proclamation $100,000 Fee, Am. Immigr. Council (Oct. 31, 2025),
https://www.americanimmigrationcouncil.org/blog/uscis-implements-h1b-100000-fee/ [https://perma.cc/5AFH-SZEU].
[46] Physicians Grassroots Network, Ask Congress to help stop H-1B visa fees, Am. Med. Ass’n,
https://physiciansgrassrootsnetwork.org/be-heard?vvsrc=%2fCampaigns%2f130422%2fRespond
[https://perma.cc/Y8D6-HVW6] (last visited Dec. 2, 2025).
[47] Brand, supra note 29.
[48] Congress Reintroduced AHA-Supported, Bipartisan Workforce Bill Supporting Foreign Nurses, Physicians, Am. Hosp. Ass’n (Sept. 11, 2025), https://www.aha.org/news/headline/2025-09-11-congress-reintroduces-aha-supported-bipartisan-workforce-bill-supporting-foreign-nurses-physicians [https://perma.cc/R6UY-EUW8].
[49] Id.
[50] AHA Letter, supra note 9; AMA Letter, supra note 6.
[51] AHA Letter, supra note 9.
[52] Id.
[53] Brand, supra note 29.
[54] Dellon, supra note 45.
