Federal visa rules threaten physician training; hospitals warn of impacts

Hospitals and medical organizations across the United States 🇺🇸 are warning that new federal visa restrictions proposed for 2025 could upend physician training just as the country braces for long-term doctor shortages. The proposals include a fixed four-year limit on international student and exchange visitor stays and a new $100,000 employer-paid fee for H-1B filings, measures that health leaders say will make it harder to recruit and keep international medical graduates (IMGs) and resident physicians. As of October 8, 2025, the changes remain under review, but the health care sector’s pushback is intense, citing risks to patient care, continuity of training programs, and the stability of hospital staffing nationwide.

Key proposed changes

• End the “duration of status” (D/S) model for F and J visa holders in favor of a fixed term capped at four years.
• Presidential proclamation (Sept 19, 2025) proposing employers pay $100,000 per H-1B application, with exemptions limited to case-by-case “national interest” waivers.
• Health leaders warn these moves would force mid-program extensions, increase bureaucratic risk, and raise hiring costs that could reduce recruitment of IMGs.

Why the four-year cap matters for physician training

Residency and fellowship tracks commonly run three to seven years, so a four-year cap is more than administrative paperwork—it affects training continuity.

• Many specialties routinely extend beyond four years (psychiatry, neurology, general surgery, and many subspecialties).
• Mid-program extension requests would become routine, opening the door to:
  • Processing delays or denials
  • Forced departures before training completion
  • Disruptions to patient care and team continuity

Hospitals argue that J-1 physicians already undergo annual sponsor oversight through ECFMG, and the four-year cap would add risk and redundancy without improving oversight.

Scope of IMGs in the U.S. workforce

• About 10% of U.S. resident physicians train on J-1 visas.
• Existing regulations allow up to seven years of GME for J-1 physicians; the proposed cap would reduce that to four.
• In 2024, 23% of all licensed U.S. physicians were foreign-trained.
  • 64% of those worked in shortage areas.
  • 46% practiced in rural communities.

These figures show IMGs disproportionately serve areas with the greatest need, particularly rural and underserved communities.

The economic impact of a $100,000 H-1B fee

• A $100,000 fee per H-1B filing would dramatically change the economics of sponsoring physicians.
• Hospitals say this could force choices such as:
  • Reducing hiring of IMGs
  • Cutting clinical services
  • Shifting funds away from patient care or educational investments
• Rural and safety-net hospitals, which rely heavily on IMGs, would likely be hit hardest.

USCIS maintains official guidance on H‑1B eligibility and procedures:
– USCIS H‑1B Specialty Occupations page: https://www.uscis.gov/working-in-the-united-states/temporary-workers/h-1b-specialty-occupations
– Form I‑129, Petition for a Nonimmigrant Worker: https://www.uscis.gov/i-129

National workforce forecasts and risks

• Projected shortfall of nearly 86,000 physicians by 2036 (estimates cited by hospital groups).
• AHA warns the gap could reach 187,130 doctors by 2037.
• Hospitals contend the proposed visa limits and fees would worsen access in communities already struggling with shortages.

Lessons from COVID-19 and flexibility concerns

• During the COVID-19 crisis, visa rules prevented 93% of IMGs on temporary visas from redeploying to surge areas, despite frontline roles.
• Hospital leaders cite this as a cautionary example: overly rigid rules limit flexibility during crises and in daily operations.

“When rules are too rigid, health systems lose the flexibility to respond to emergencies.”
Hospital leaders warn the four-year cap and six-figure fee would embed such rigidity into everyday care delivery.

Impact on training programs and patient care

• Residency and fellowship programs would need to plan for mid-program extension filings and possible delays.
• Consequences of delayed or denied extensions:
  • Reshuffled schedules and coverage gaps
  • Potential loss of board eligibility timelines and delayed graduations
  • Vacancies that are hard to backfill mid-year
• Specialty-specific impacts:
  • Psychiatry and neurology residencies often already span four years.
  • General surgery commonly runs five years, plus fellowships.
  • Pediatric subspecialties (e.g., neonatology, pediatric critical care) add years beyond base training.

Continuity of care concerns:
– Patients in long-term treatment relationships (oncology, epilepsy, psychiatry, maternal-fetal medicine) would face disruptions if trainees are forced to leave.
– Trust and care plans built over years can be undone by abrupt departures.

Administrative and legal pathway complications

• Typical legal transitions: J-1 → H-1B → fellowship → attending position → possible waiver for service in shortage areas.
• Each stage involves forms, fees, and precise timing; added cost or uncertainty can deter physicians from the U.S.
• H-1B filings require Form I-129, prevailing wage checks, site attestations, and potentially inspections—now proposed to carry a six-figure additional fee.

Advocacy positions and suggested alternatives

Hospital associations and medical societies (including AMA and AHA) are asking for:

• Keep the current D/S framework for J-1 physicians.
• Categorical exemptions for physicians, residents, and fellows from the H-1B fee—rather than case-by-case “national interest” waivers.
• Their arguments:
  • IMGs fill positions that would otherwise remain vacant, especially in rural and underserved areas.
  • Categorical relief reduces administrative backlogs and planning uncertainty.
  • Existing sponsor oversight (e.g., ECFMG) already provides structured compliance.

VisaVerge.com analysis notes that categorical exemptions for health personnel have precedent and could protect critical services.

Practical steps hospitals and trainees are taking now

Hospitals and training programs are preparing for scenarios where the proposals are finalized:

• Program-level actions:
  • Map residency/fellowship timelines to identify trainees who would hit a four-year limit.
  • Plan early extension filings where possible.
  • Build cross-coverage and staffing buffers to handle processing delays.
• Documentation preparation:
  • Collect proof of program standing, rotation schedules, letters from directors, and other supporting materials for extension filings.
• Budget and recruitment planning:
  • Analyze budgets with a potential $100,000 per H-1B fee in mind.
  • Flag positions where “national interest” arguments might apply if exemptions remain case-specific.
  • Consider shifting some recruitment toward J-1 pathways (noting return-home rules and waiver constraints).

Advice for trainees and applicants:
– Review program visa sponsorship policies.
– Ask institutions how they would manage mid-program extension needs.
– Understand differences between J-1 and H-1B pathways and how they align with intended training length.
– Gather documentation that could support extension petitions if needed.

For policy questions, the AAMC recommends contacting:
– Bradley Cunningham: [email protected]
– Jodi Yellin: [email protected]

Stakes and possible outcomes

• If the proposals move ahead as written, hospitals warn of:
  • Hard choices about what services to staff
  • Fewer doctors in already stretched communities
  • A steeper climb to close projected workforce gaps
• If exemptions are granted and the D/S framework remains:
  • Health leaders believe the system can absorb the changes without breaking the training pipeline

Hospitals, medical schools, and training programs are actively:
– Sending comment letters
– Compiling data on workforce needs and program timelines
– Sharing frontline stories to illustrate real-world impacts

Their stated goal: protect program integrity while keeping doors open for the international medical graduates who have long strengthened the U.S. physician workforce. Whether through categorical exemptions, targeted revisions, or both, the policy outcome should support a simple objective: keep patient care steady and physician training intact where doctors are needed most.