Small rural hospitals that rely on internationally trained staff are confronting a sharply higher cost to recruit foreign workers after a new presidential proclamation introduced a $100,000 H‑1B fee for applicants applying from abroad.
At West River Health Services, a tiny hospital in Hettinger, North Dakota, hiring has already become a painful exercise. Bekki Holzkamm, who has been trying to fill a lab technician role since late summer, says no U.S. applicants responded. Faced with a vacancy, the hospital must weigh four difficult choices: pay the new six‑figure charge to bring in an overseas candidate, seek a limited waiver from the Department of Homeland Security, intensify domestic recruiting that has so far failed, or leave the post vacant and stretch an already thin staff.
Before the proclamation, employers typically spent up to roughly $5,000 to sponsor an H‑1B worker. The new policy targets foreign nationals applying from outside the United States; workers who are already in the country on other visas are largely exempt. For many small rural systems, a $100,000 fee equals the annual salary for multiple employees and can make hiring nurses, lab techs, therapists and other clinicians from abroad financially impractical.
West River has long relied on immigrant hires. Kathrine Abelita, a lab technician from the Philippines who joined the hospital in 2018 and is now a permanent resident, warned the change could be devastating for facilities that already struggle to attract talent. Rural hospitals depend on internationally trained clinicians to fill persistent gaps: a 2023 government survey found immigrants comprise about 16% of registered nurses and roughly 14% each of physician assistants and nurse practitioners and midwives in U.S. hospitals. Licensing data from 2024 show nearly a quarter of U.S. physicians trained outside the United States or Canada.
Although the proclamation was presented as a response to alleged misuse of H‑1B visas in the tech sector, its scope reaches beyond technology employers and affects health care providers too. Hospital associations and rural health organizations — including the American Hospital Association, the National Rural Health Association and the National Association of Rural Health Clinics — along with more than 50 medical societies, have urged the administration to exempt health care workers. They argue the fee will hit rural communities particularly hard, where budgets and recruitment options are limited.
The proclamation does allow for waivers in tightly defined situations, such as when an exemption would serve the national interest or when an employer demonstrates there are truly no qualified American workers and that the fee would meaningfully undermine U.S. interests. New guidance, however, says waiver approvals will be reserved for exceptionally rare cases. Hospital leaders and immigration attorneys warn that this high standard leaves hospitals uncertain whether a waiver will be granted or how long the process may take.
Hospitals and rural advocacy groups say their appeals for an exemption have received little response. DHS officials have directed questions to the White House, which has defended the policy as prioritizing American workers and curbing perceived H‑1B misuse.
One important nuance: the fee generally does not apply when employers sponsor H‑1B status for workers already in the United States. That distinction matters for many physicians, who commonly come to the U.S. on J‑1 visas for residency and may convert to H‑1B status — often through the Conrad 30 waiver program that requires service in underserved areas — without facing the new charge. By contrast, many nurses, lab technologists, physical therapists and other nonphysician clinicians apply from overseas and would trigger the six‑figure fee.
Rural health groups estimate nearly 1,000 H‑1B health care workers currently serve in rural areas. Hospital executives in states such as Nebraska and North Dakota say the fee will complicate hiring for nonphysician roles that historically have been filled by overseas recruits. At West River, CEO Alyson Kornele says the system cannot absorb the new cost and is shifting efforts toward local recruitment and retention — efforts that have delivered few hires because the hospital cannot match urban salaries and younger workers often prefer metropolitan areas.
The policy has also prompted legal and political pushback. At least two lawsuits seek to block the fee: one filed by a recruiter of foreign nurses and a union representing medical graduates, and another brought by the U.S. Chamber of Commerce, which cites impacts on physician shortages and the financial strain on health systems. Lawmakers from both parties have signaled concern. Senate Majority Leader John Thune has said he intends to pursue possible exemptions and has urged policies that make it easier and less costly to secure needed health care workers. Medical societies, including the American Medical Association, have pressed the administration to change course, warning that rural patients could be unintended casualties.
Observers also note ethical and international consequences: the United States’ dependence on clinicians trained abroad can deepen workforce shortages in lower‑income countries that invested in educating those professionals. That dynamic stems from long‑running trends — population growth, limited expansion of domestic medical education and unequal access to training — which make hiring trained foreign clinicians a cheaper short‑term fix than building U.S. training capacity.
With waivers narrowly defined and approval timelines uncertain, rural hospitals face stark choices: pay the fee and cut other services, rely on an uncertain waiver process, redouble local hiring initiatives that often fall short, or leave positions empty and push remaining staff to cover more work. For small facilities already operating with minimal staffing, the new H‑1B fee risks intensifying shortages and jeopardizing access to care in underserved communities.