Rural Hospitals Face $100,000 H-1B Fee as New Policy Takes Effect

(UNITED STATES) Rural and underserved hospitals across the United States 🇺🇸 say they are facing a new financial barrier to hiring foreign doctors after the federal government imposed a $100,000 supplemental fee on certain initial H-1B visa petitions. The policy, announced by presidential proclamation on September 19, 2025, took effect for filings made on or after September 22, 2025, and applies to new H-1B petitions for workers outside the country who do not already hold a valid H-1B. Hospital leaders warn the added cost could make it impossible to bring in international medical graduates—clinicians who help keep emergency rooms open and primary care clinics staffed in areas already short of doctors.

Hospital groups describe the fee as financially unworkable for many facilities with thin margins, especially those in rural and medically underserved regions. Administrators say a single supplemental fee at this level can equal months of payroll for a small clinic, or the budget for a nurse practitioner program that serves thousands of patients. The result, they argue, will be longer wait times, unfilled positions, and reduced access to care in communities with fragile health systems.

The new charge is on top of standard H-1B costs and must be paid by the employer through an online portal, with proof of payment or evidence of an approved exception included at filing. According to current government guidance, the supplemental fee applies only to new petitions for beneficiaries outside the U.S. and does not apply to current H-1B holders, extensions, amendments, or individuals already in the country. As of October 27, 2025, there is no categorical exemption for physicians or other healthcare workers.

Policy changes and the National Interest Exception

Under the policy, employers that seek to sponsor a worker who is abroad and does not already hold H-1B status must pay the $100,000 charge at the time they submit the petition.

The government has created a National Interest Exception (NIE) process, but it is not automatic. Employers must demonstrate that:

• The worker is essential to the national interest.
• No American worker can fill the role.
• Paying the fee would undermine the national interest.

Health systems note the NIE process is discretionary, case-by-case, and administratively heavy. There is no blanket rule that covers doctors, nurses, or allied health staff. For small or rural hospitals that lack large legal or compliance teams, preparing a strong NIE request can be daunting and slow, with uncertain outcomes. Many say they will have to choose between paying the fee, which they cannot afford, or leaving critical positions empty.

Rural and underserved hospitals rely heavily on international medical graduates (IMGs) to fill primary care and specialty roles that often go unfilled by U.S.-trained doctors. Leaders in these communities say the fee disrupts well-known pathways—such as the J-1 waiver route followed by an H-1B—which have long helped place physicians in shortage areas. If the H-1B step becomes cost-prohibitive, fewer doctors may choose or be able to serve in these communities.

Impact on communities, hospitals, and staffing

Hospital executives and medical societies describe a clear chain reaction from the new H-1B fee:

• The fee diverts scarce funds from patient care. Facilities may pull money from mental health programs, maternity care, or outreach clinics to cover a single petition, if they can cover it at all.
• Hiring delays are likely to stretch for months or longer. With positions unfilled, patient panels grow and waiting rooms swell.
• Reliance on locum tenens and temporary staffing rises. Short-term staff can cost far more than salaried hires, quickly draining budgets.
• Physician retention suffers. If teams are short-staffed, burnout climbs, and departures may follow.
• Communities lose trust when services shrink. Patients who already travel long distances for care may face even fewer options.

The concern is not theoretical:

• IMGs make up about one in four practicing physicians nationwide, with many working in rural or underserved communities.
• The U.S. faces a projected shortage of up to 86,000 doctors by 2036, a gap felt most in small towns and low-income neighborhoods.

Hospital leaders fear the supplemental fee will worsen shortages where they are already most severe.

Major organizations are pressing for relief. The American Hospital Association (AHA) and the American Medical Association (AMA), along with dozens of state and specialty societies, have urged the Department of Homeland Security to exempt physicians and other healthcare workers from the fee. They argue that foreign-trained clinicians do not displace U.S. workers in these cases; instead, they help maintain services that might otherwise close. As of October 27, 2025, their advocacy has not led to a categorical exemption, and hospitals must either pay the fee or attempt the NIE process.

Administrators also warn of a broader talent shift: with the cost spike and uncertainty in the U.S. system, some IMGs may choose other countries where rules are more predictable and costs lower. That could leave rural hospitals with even fewer candidates willing to serve in areas already designated as Health Professional Shortage Areas.

According to analysis by VisaVerge.com, the fee’s real-world effect is most visible in hiring plans. Recruiters say positions they intended to fill this winter are now on hold while finance teams review the budget impact. For a 30-bed hospital that planned to hire two family medicine doctors and a hospitalist from abroad, the $300,000 in added costs equals the price of a new ultrasound machine, an ambulance, and a year of community health outreach combined.

Implementation details and immediate steps for hospitals

Hospitals that still plan to hire under the new rules face a practical decision tree. Some can absorb the cost for a single critical hire—say, an emergency physician needed to keep the ER open 24/7—but not for multiple roles. Others will try the National Interest Exception, knowing the burden of proof is high and outcomes are not guaranteed.

Key operational details now in effect:

• Effective date: Applies to petitions filed on or after September 22, 2025.
• Scope: Applies to new H-1B petitions for beneficiaries outside the U.S. without a valid H-1B; does not apply to current H-1B holders, extensions, or amendments.
• Payment: Employers must pay through an online portal and include proof of payment or proof of an approved exception with the filing.
• Exceptions: NIE is case-by-case; no blanket exemption for healthcare workers at this time.

Hospital associations recommend several short-term actions:

1. Screen upcoming recruiting plans and identify roles that may require the fee.
2. Consider whether any positions meet the NIE standard and gather evidence early, including:
   • Community health data
   • Recruitment records
   • Statements from medical directors
3. Engage local, state, and national partners to coordinate advocacy while tracking federal updates.

For official government guidance and updates on H-1B policies and employer requirements, consult the U.S. Citizenship and Immigration Services website at USCIS H-1B.

Effects on training pipelines and patient access

The timing complicates academic-year planning for residents who finish training and plan to work in shortage areas. Many IMGs complete residencies through J-1 programs and then seek to serve in rural locations under waiver commitments, moving next to an H-1B for employment.

If the H-1B step now carries a six-figure supplemental fee, both physicians and hospitals may reconsider offers. Some hospitals say they will redirect recruitment toward telehealth or part-time specialists, which can help but does not replace a full-time local doctor in a clinic.

Healthcare leaders stress the human cost in concrete terms:

Closed clinic days, long drives for dialysis or prenatal care, and delayed cancer screenings are measurable harms. A county that loses a single internal medicine physician can see thousands of appointments vanish each year. When an OB-GYN hire falls through, expectant mothers may need to travel across county lines to deliver.

The new fee, they say, compounds these strains by pricing out a vital hiring channel.

Advocacy, adaptation, and near-term outlook

Advocacy efforts continue. The AHA and AMA maintain that protecting access to care is a matter of national health security, arguing that an exemption for physicians and critical hospital staff would prevent disruptions without weakening the policy’s broader goals. Hospital executives add that a clear, simple pathway reduces compliance costs and makes it easier for small facilities to plan.

For now, rural hospitals face a stark choice: pay the fee, seek the NIE, or leave posts empty. Each option carries trade-offs:

• Paying the fee might mean deferring equipment purchases or cutting outreach.
• Pursuing the NIE could save money but adds uncertainty and legal workload.
• Leaving positions empty risks burnout for current staff and longer waits for patients.

In the months ahead, hiring patterns will reveal how hospitals adapt. Potential responses include:

• Concentrating hiring on roles most likely to qualify for an exception (specialties with documented shortages).
• Forming regional partnerships to share specialists.
• Expanding nurse practitioner–led clinics to bridge gaps.

Many leaders say these measures only go so far if physician seats remain empty.

Hospitals and medical groups advise close monitoring of official announcements in case the government adjusts the policy or clarifies the exception framework. Until then, the H-1B fee will remain a central line item in rural health budgets—and a test of how immigration policy choices ripple through the daily lives of patients and providers in communities that can least afford another hurdle.