President Trump's September 19, 2025, executive order raising H-1B visa petition fees from approximately $3,500 to $100,000 threatens to exacerbate physician shortages in the nation's medically underserved communities, according to a Research Letter and Viewpoint published in JAMA.
The proclamation, which took effect September 21, 2025, and will last 12 months unless extended, was framed as stopping H-1B "abuse" in science, technology, engineering, and mathematics fields. However, the policy also affects physicians who fill gaps, particularly in rural communities during the current workforce crisis.
Geographic Disparities in H-1B Physician Distribution
A cross-sectional study analyzing all certified Labor Condition Applications supporting H-1B visas in fiscal year 2024 found that H-1B-sponsored health care professionals accounted for 1% of physicians (11,080 of 1,138,056), 0.02% of advanced practice providers (122 of 641,605), 0.4% of dentists (1,004 of 251,551), and 0.07% of other health care workers (132 of 181,495).
Counties with the highest poverty levels had a higher percentage of H-1B-sponsored physicians than counties with the lowest (2% vs 0.5%), and rural counties exceeded urban counties (1.6% vs 1%). Rates were highest in the Northeast (1.4%), followed by the Midwest (1.2%), South (0.8%), West (0.5%).
Workforce and Economic Context
The Association of American Medical Colleges projects a national physician shortage of 13,500 to 86,000 by 2036, while the Health Resources and Services Administration (HRSA) reports 7,749 primary care health professional shortage areas (HPSAs) affecting approximately 77.3 million residents. Eliminating these shortages would require 13,364 additional primary care physicians, and 66.4% of HPSAs are rural.
International Medical Graduates and the Conrad 30 Waiver
International medical graduates account for about one-quarter of US physician workforce and are more likely than US medical graduates to work in shortage areas. Many complete training on J-1 visas and transition to H-1B status using the Conrad 30 waiver (a 3-year underserved-area commitment). Between 2001 and 2020, Conrad 30 recruited 18,504 physicians (a 111% rise in annual recruitment) and reduced unfilled state slots from 950 to 338.
Under the Conrad 30 waiver program, employers must show recent, unsuccessful recruitment efforts to hire a US physician before they are allowed to sponsor an international medical graduate physician using the H-1B program, noted Omar Abughanimeh, MBBS, of the Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center–Fred and Pamela Buffett Cancer Center, and Mouhanna Abu Ghanimeh, MBBS, of the Department of Gastroenterology, Sanford Health.
The AMA estimates each physician contributes to approximately 17 jobs and $3.2 million in economic output.
Predicted Effects on Health Systems
"A sudden, substantial cost imposed at the point of entry will predictably fall hardest on institutions least able to absorb it, likely rural health care systems that are already wrestling with staffing vacancies and financial issues," the Viewpoint authors write. After the 2016 Medicare GME funding cut, many programs stopped H-1B sponsorship to reduce costs and switched to J-1 visas; hospitals may see similar effects when hiring international medical graduate trainees.
Switching to J-1 visas following training is not viable, as the J-1 requires a 2-year home-country residency, demands nonimmigrant intent, is administered by ECFMG, prevents independent practice, and offers no direct path to permanent residency.
National Interest Exemptions
The current proclamation includes an exception if the job serves the national interest and does not threaten the security or welfare of the US. In addition, a June 4, 2025, proclamation initially suspended entry and certain visas (including J-1 for 19 countries) with case-by-case exceptions; the Department of State subsequently resumed processing and instructed embassies to prioritize J-1 physicians for interviews. Physicians with H-1B visas are exempt from the program cap.
Study Limitations
Relying on H-1B application data may overestimate the number of health care professionals who ultimately enter on H-1B visas, though approximately 94% were approved in FY2024.
As the Viewpoint authors write: "The only standard that should guide immigration policy in health care is this: does it help patients receive timely, high-quality care? If not, it must be changed." They concluded, "Finally, patients can't wait. Amid the current staffing crisis, policies should bring physicians to the bedside, not push them away."
Disclosures: See the published Research Letter.
Source: JAMA Research Letter, JAMA Viewpoint