By Arielle Zionts, Phillip Reese
December 8, 2025 / 5:00 AM EST / KFF Health News
Bekki Holzkamm has been trying to hire a lab technician at West River Health Services, a small hospital in Hettinger, North Dakota, since late summer. No U.S. citizens applied. The hospital faces four unappealing options: pay the Trump administration’s new $100,000 H‑1B visa fee to hire a qualified applicant from abroad, ask the Department of Homeland Security for a waiver, keep recruiting domestically, or leave the position unfilled and increase strain on an already thin staff.
Before the presidential proclamation issued in September, employers typically paid up to about $5,000 to sponsor an H‑1B worker. The new six‑figure charge applies to foreign workers applying from outside the U.S.; those already in the country on other visas are generally exempt. For small rural hospitals, the fee can equal a year’s pay for multiple staff members, creating a steep barrier to hiring internationally trained technicians, nurses, and other clinicians.
West River employs many people who once held H‑1B visas. Lab technician Kathrine Abelita, from the Philippines, has worked there since 2018 and is now a permanent resident. She and others warn the fee could be devastating for rural facilities that already struggle to recruit. “It’s going to be a big problem for rural health care,” Abelita said, noting that many younger U.S. workers prefer urban areas.
Immigrants make up a substantial share of the hospital workforce: a 2023 government survey found 16% of registered nurses, 14% of physician assistants, and 14% of nurse practitioners and midwives in U.S. hospitals are immigrants. Nearly a quarter of U.S. physicians trained outside the U.S. or Canada, according to 2024 licensing data. Rural hospitals rely on this international workforce to fill persistent shortages.
The proclamation was framed as a response to alleged misuse of H‑1B visas by tech firms, but it applies across sectors, including health care. Advocacy groups — the American Hospital Association, national rural health organizations, and more than 50 medical societies — have asked the administration to exempt health care providers, arguing the fee will disproportionately harm rural communities that already struggle to pay for and recruit providers. The National Rural Health Association and the National Association of Rural Health Clinics urged a blanket exception as the simplest fix.
The proclamation allows fee waivers in limited circumstances, such as when granting the exemption is in the national interest or the employer can show there is truly “no American worker” available and that the fee would “significantly undermine” U.S. interests. New guidance says waivers will be reserved for “extraordinarily rare” situations. Immigration attorneys and hospital leaders say that standard is exceptionally high and creates uncertainty about whether and how long any waiver request would take.
Hospitals and rural health groups report limited or no response from the administration to their requests. Homeland Security officials referred questions to the White House, which defended the fee as a measure to “put American workers first,” echoing the proclamation’s aim to curb perceived H‑1B misuse by tech companies.
The administration’s policy does carve out a key nuance: it does not require the fee for employers who sponsor H‑1B workers already inside the U.S. That matters because many foreign physicians who train in the U.S. arrive on J‑1 visas for residency and, under the Conrad 30 Waiver Program, may remain and apply for H‑1Bs if they commit to work in underserved areas for three years. Those already in the country through J‑1 waivers generally avoid the new fee. But many nurses, therapists, and technicians apply from abroad and would trigger the six‑figure cost.
Rural health groups estimate nearly 1,000 H‑1B health care workers currently work in rural areas. Hospital leaders say specialists such as nurses, lab technicians, and physical therapists often apply from overseas, unlike physicians who commonly change status while in the U.S. Chief executives at rural systems in Nebraska and North Dakota said the new fee will complicate recruiting those nonphysician roles.
The fee is already changing hospitals’ strategies. West River’s CEO, Alyson Kornele, said the hospital cannot afford the $100,000 charge and is refocusing on local recruitment and retention. But Holzkamm has had little success hiring local graduates and interns, and the hospital cannot match urban salaries. “It’s a bad cycle right now. We’re in a lot of trouble,” she said.
The administration faces legal challenges to the fee. At least two lawsuits seek to block it — one filed by a recruiter of foreign nurses and a union representing medical graduates, and another by the U.S. Chamber of Commerce, which cites concerns about physician shortages and the fee’s economic burden on health systems.
Lawmakers from both parties have expressed concern. Senate Majority Leader John Thune said he planned to pursue possible exemptions, calling for policies that make it “easier, not harder, and less expensive, not more expensive, for people who need the workforce.” The American Medical Association and other medical groups are pressing the administration for changes, arguing rural health care will be collateral damage if the fee stands as written.
Experts also note broader ethical and global implications: the U.S. reliance on internationally trained providers can exacerbate shortages in lower‑income countries that invest in training clinicians who then migrate. That dependency arises from long‑term trends — population growth, limited expansion of domestic medical education, and historically unequal access to training — which have made importing trained professionals a cheaper short‑term solution than scaling U.S. training programs.
With waivers limited and timelines unclear, rural hospitals face difficult choices: absorb the cost and reduce other services, gamble on a waiver that may not come, redouble local hiring efforts that often fail, or leave positions unfilled and stretch existing staff. For small facilities already operating with skeleton crews, the new H‑1B fee could deepen staffing crises and threaten access to care in underserved communities.
Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University‑Sacramento.
KFF Health News is a national newsroom that produces in‑depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling