H-1B visa fee strains the healthcare workforce and hospital finances

In the year after implementation of a new White House policy curtailing the pipeline for legal immigration, the healthcare industry is grappling with the implications.

In September, the Trump administration announced that the H-1B visa program for skilled workers seeking to enter the U.S. would carry a $100,000 fee per application. Healthcare, along with higher education, stands to be particularly affected as it seeks to fill gaps in a specialized workforce. Before the announcement, employers generally paid a few thousand dollars per application.

“It has had some pretty negative impacts,” Maria Kallmeyer, an employment-focused immigration attorney with Quarles & Brady, LLP, said regarding the increase.

For many hospitals, especially those in rural areas or serving the healthcare safety net, the imposed costs may be unsustainable, said an expert who works in nurse staffing.

“They simply cannot afford it, so that has taken them out of the equation for H-1B candidates, and what that does is additional strain is now added to those systems,” said Ann-Rose Johnson-Lewis, director of legal services at WorldWide HealthStaff Solutions.

The situation is a contributor to the shortfall of registered nurses, she said. A new survey from the industry finds that a third of all hospitals have a vacancy rate of 10% or higher.

Still, the restrictions are likely to affect the hiring of physicians more so than nurses. A recent study found that in 2024, physicians with H-1B visas represented nearly 1% of the U.S. supply, at more than 11,000 nationwide. For nursing, the program generally is limited to advanced-practice roles because H-1B job requirements typically must include a four-year degree.

Legal challenges to the $100,000 fee

The H-1B fee is being challenged in multiple lawsuits, including a case brought by a coalition of unions, nonprofits, religious organizations and the healthcare staffing firm Global Nurse Force. Plaintiffs argue, in part, that the fee effectively is a tax and thus needs congressional authorization.

“Directly hiring skilled nurses on H-1B visas allows healthcare systems to meet their staffing needs without relying on short-term hiring of so-called ‘travel nurses,’ which is a far more expensive staffing solution that, in a year, can cost healthcare systems millions of dollars more in fees paid to staffing providers,” the court filing states.

The filing describes an unnamed system in Louisiana that had gone through the process of selecting 200 international nurses before the new fee was levied.

“The healthcare system is now at a loss for how to fill the staffing shortages that are affecting its patients,” according to the complaint.

In a November 2025 survey of its members, the American Hospital Association found that 64% of respondents that utilized H-1B now planned to pause, defer or limit recruitment.

Another plaintiff in the Global Nurse Force case is the Committee of Interns and Residents, a branch of the Service Employees International Union that represents hospital interns, residents and fellows. The $100,000 fee “places [visa] sponsorship entirely out of reach for the very medical facilities Congress intended to benefit for these programs,” the filing states

Two other challenges to the fee were filed by the U.S. Chamber of Commerce and by a coalition of roughly 20 states. In the first big ruling among the three cases, the U.S. District Court for Washington, D.C., granted the government a summary judgment in the Chamber case. That decision is under appeal.

Operational challenges in international hiring

Hospitals use the H-1B program to expedite the hiring of clinicians from overseas. A nurse generally can be brought aboard within three to six months, compared with 18 to 30 months via the EB-3 permanent-visa program. Kallmeyer said EB-3 also has become more difficult in recent years because applications have exceeded availability.

Among international physicians, many train in the U.S. while in J-1 work-study visa status as part of their residency or fellowship, Kallmeyer said. Typically, they then have to return to their home country and work for two years.

Waivers of that requirement are available to physicians who commit to serve in a U.S. rural or underserved area under H-1B status. Hospitals in those areas are disproportionately reliant on that pipeline, Kallmeyer noted.

But the $100,000 fee now applies to some of those physicians, often due to procedural reasons around immigration status rather than because the physician actually lives abroad. The fee thus has “become an additional barrier in a way that maybe it wasn’t even intended,” Kallmeyer said.

The fee is likely to reduce the supply of physicians willing and able to work in underserved areas, she added, thereby undermining the policy goal of the J-1 program.

“By preventing those physicians from working in the U.S. after their training, it’s almost like wasting their training if you’re thinking from a U.S. government perspective,” Kallmeyer said. “They can certainly use their training in their home country or some other place, but whatever benefit the U.S. had from training them in the U.S., we’re not getting.”

Policy rationale and labor market debate

The White House says H-1B has stymied the domestic labor market across industries: “American workers are being replaced with lower-paid foreign labor, creating an economic and national security threat to the nation,” according to a fact sheet issued when President Donald Trump announced the fee.

The administration made similar points in a court filing in the Global Nurse Force case: “To the extent that hospital facilities are willing to pay domestic nurses more in light of the H-1B Proclamation (and thus incentivizing nursing careers domestically) now that demand for nurses is higher, then the H-1B Proclamation will have worked as intended.”

Hiring internationally does not undercut the wage structure for domestic clinicians, noted Johnson-Lewis and Laura Messineo, chief nursing officer with WorldWide, because the U.S. Department of Labor sets a wage framework for all occupations that are subject to the H-1B program. That payment floor is based on wage surveys, and it accounts for geographic variation.

Added Johnson-Lewis, “And then from there, depending on the qualification of the nurse, that wage will go up — sometimes to the point where you may see a hospital system saying, ‘We don’t pay our first-year nurses this much, but you’re telling me I have to pay an international nurse this much?’”

Other immigration policy developments to monitor

Another concern regarding clinical workforce policy is the Trump administration’s recent decision to reclassify registered nursing from professional to nonprofessional. The designation affects the loan amounts available to nurses for their graduate education under new rules.

The domestic nursing supply could be further constrained as a result of the change. In turn, international recruitment would become more viable, but less so given the new restrictions on visa policies, Johnson-Lewis said.

Other impediments to hiring international clinicians include an adjudication pause on applications for prospective immigrants from nearly 40 countries. For example, Kallmeyer represents two Venezuelan physicians “who have done everything right. They are caring for American patients, in [terms of] status they’re legal, they followed all the rules throughout their whole career.”

Because of the pause in application processing by the U.S. Citizenship and Immigration Services, “They’re not being adjudicated. They’re losing work authorization and having to essentially stop seeing patients.”

The big picture remains murky

It’s too early to quantify the impact of the H-1B fee and other changes.

“We’re just seeing it be harder and cost more and be more onerous, and I’m sure that difficulty will at some point result in less people coming,” Kallmeyer said. “If you look at statistics, you probably won’t see that yet, but I am seeing that on the ground.”

Kallmeyer said the most compelling solution is comprehensive immigration reform, looking at “the whole system holistically [to] figure out the gaps.”

While that outcome seems like a longshot in the current political environment, hospitals and health systems perhaps can help spur action, given their status as pillar organizations in their communities, she said: “Having Congress understand what the needs of healthcare organizations are and where having additional people in the United States could fill in those gaps.”