Trump administration’s new $100,000 H1-B visa fees could leave rural health care as collateral damage

Becky Holtzkamm has been trying to hire a lab technician at a hospital in rural North Dakota since late summer.

No US citizens applied.

West River Health Services in Hettinger, a town of about 1,000 residents in the southwestern part of the state, offers four options, and none of them are suitable.

Hospital may provide more than $100,000 to help Trump administration new H-1B visa fee and hire one of over 30 applicants from the Philippines or Nigeria. The fee is equivalent to what some rural hospitals pay two lab technicians a year, said Holzkamm, the West River lab manager.

West River may ask the Department of Homeland Security to waive the levy. But it is unclear how long the waiver process will take or whether the government will provide one. The hospital may continue to try to hire someone from the US for the job. Or, Holzkamm said, it could leave the vacancy unfilled, increasing the workload of the current “skeleton crew.”

The U.S. health care system depends on foreign-born professionals to fill the ranks of doctors, nurses, technicians and other health care workers, especially in chronically understaffed facilities in rural America.

But the new presidential declaration aimed at technology industry use The H-1B visa makes it difficult for West River and other rural service providers to hire these workers.

“The healthcare industry wasn’t even considered. They will be collateral damage, to such an extreme degree that it clearly hasn't been thought of at all,” said Eram Alam, a Harvard assistant professor whose new book explores the history of foreign doctors in the United States.

Elissa Taub, a Memphis, Tennessee-based attorney who helps hospitals with the H-1B application process, has heard concerns from her clients.

“This does not mean that there is a surplus of American doctors or nurses waiting in the wings for these positions,” she said.

Until recently, West River and other employers paid up to $5,000 each time they applied to sponsor an H-1B worker. The visas are for highly skilled foreign workers.

New $100,000 fee – part a. September Proclamation from President Trump – applies to workers living outside the US, but not to those already in the US on a visa.

West River lab technician Katherine Abelita is one of nine employees — six technicians and three nurses — at the hospital who are current or former H-1B visa holders. Abelita is originally from the Philippines and has been with West River since 2018. Now she permanently resides in the USA.

“This is going to be a big problem for rural health care,” she said of the new tariff. She said most young American workers want to live in urban areas.

Sixteen percent of registered nurses, 14% of physician assistants, and 14% of nurse practitioners and midwives working in U.S. hospitals are immigrants, according to the study. State survey 2023. Nearly a quarter of doctors in the United States attended medical school outside the United States or Canada, according to the data. Licensing data 2024.

American Hospital Associationtwo national rural health organizationsAnd more than 50 medical societies asked the administration to grant the healthcare industry an exemption from the new fee. The groups argue that the new cost will disproportionately harm rural communities that already struggle to afford and employ enough service providers.

“A complete exemption for health care providers is the simplest path forward,” the National Rural Health Association and the National Association of Rural Health Clinics wrote in a joint letter.

The ruling allows for duty waivers for individuals, employees of specific companies and employees of entire industries when “it is in the national interest.” New management says the fee will only be waived in “extremely rare circumstances.” This includes proving that there are “no American workers available” for the position and that requiring the company to spend $100,000 would “significantly undermine” U.S. interests.

Taub called the standards “exceptionally high.”

Representatives for the NRHA and the American Medical Association, which organized the letter from the medical societies, said they had not received a response after sending queries to Homeland Security Secretary Kristi Noem in late September and early October. The AHA declined to say whether it had received a response.

Homeland Security officials referred KFF Health News inquiries to the White House, which did not respond to questions about individual waiver timelines or the possibility of a categorical exemption for the health care industry.

Instead, White House spokesman Taylor Rogers issued a statement defending the new tariff, saying it would “put American workers first.” Her comments echoed Trump's statement, which focused on accusations that the tech industry is abusing the H-1B program by replacing American workers with low-wage foreign workers. But the order applies to all transactions.

Alam, the Harvard professor, said the U.S. dependence on international service providers does raise legitimate concerns, such as how it draws talent away from low-income countries that face even greater health problems and workforce shortages than the United States.

This decades-long dependence, she said, stems from a population boom, the historical exclusion of non-white men by medical schools and the “much, much cheaper” cost of importing foreign-trained providers than the expansion of medical education in the United States.

According to internationally trained professionals, doctors tend to work in poor and underserved rural and urban areas. survey And research review.

Nearly 1,000 H-1B providers were employed in rural areas this year, two rural health organizations wrote in a letter to the Trump administration.

The J-1 visa, the most common type received by foreign doctors during residency and other graduate training in the United States, requires them to return to their home country within two years before applying for an H-1B visa.

But a government program called the Conrad 30 Waiver Program allows up to 1,500 J-1 holders a year to remain in the U.S. and apply for H-1B in exchange for working for three years in a provider shortage area that includes many rural communities.

President Trump said in a statement that employers who sponsor H-1B workers already in the U.S., such as doctors with these benefits, will not have to pay the six-figure fee. This nuance is clarified in a guide published about a month later.

But employers will have to pay a new fee when hiring doctors and other applicants living outside the United States.

Alison Cornele, CEO of West River Health Services, said most of the foreign nurses and lab technicians it hires are outside the U.S. when they apply.

Ivan Mitchell, CEO of Great Plains Health in North Platte, Nebraska, said most of his H-1B hospital doctors were in the U.S. on other visas when they applied. But he said physiotherapists, nurses and laboratory technicians routinely seek help from overseas.

Holtzkamm said it took five to eight months to hire H-1B applicants at her lab before the new fee was implemented.

Bobby Mukkamala, a surgeon and president of the American Medical Association, said Republican and Democratic lawmakers are concerned about the impact on rural health care.

They include Senate Majority Leader John Thune, who has said he plans to discuss possible exceptions.

“We want to make it easier, not harder, and cheaper, not more expensive, for people who need labor,” the Republican told KFF Health News in September.

Thune's office did not respond to questions about whether the senator had heard from the administration about potential benefits for health care workers.

The Trump administration is facing at least two lawsuits trying to block the new tariff. One group of plaintiffs includes a company that hires foreign nurses and a union that represents medical graduates. Another lawsuitUS Chamber of Commerce, mentions concerns about the shortage of doctors and the ability of health systems to afford the new fees.

Cornele said West River won't be able to afford the $100,000 fee, so he's doubling down on efforts to recruit and retain local employees.

But Holzkamm said she hasn't been able to find lab technicians from North Dakota colleges, even those doing hospital internships. She said West River can't compete with the salaries offered in larger cities.

“It’s a bad cycle right now. We have big problems,” she said.

Philip Reese is a data scientist and assistant professor of journalism at California State University, Sacramento.

KFF health news is a national news service that produces in-depth journalism on health issues and is one of the primary operating programs in KFF is an independent source of health policy research, polling and journalism.