By Dr. Jim Dahle, WCI FounderPresident Trump has instituted a $100,000 fee for H-1B visas. The explanation for this fee in the Sept. 19, 2025, presidential proclamation was to prioritize the hiring of American workers instead of foreigners. Basically, that foreigner had better be at least $100,000 better than a comparable American, or companies will hire the American. Commerce Secretary Howard Lutnick called the H-1B visa program the “most abused visa” and further explained that this fee was intended to stop tech companies from exploiting the program. The fee is supposed to stop companies from “spamming the system” and driving down wages.
Like many announcements by the Trump administration, this one came suddenly and caused lots of chaos on a weekend (the weekend I wrote this) as people scrambled to understand what was happening. Then, it was almost immediately changed/clarified after the initial announcement. The $100,000 payment was initially understood to be an annual fee, but it is not; it's a one-time fee. It also only applies to NEW visa holders, not those already here on a visa.
We don't comment on every economic action taken by the administration, but this is an issue worth discussing here at WCI. Lots of doctors train in the US on H-1B visas, and some attendings remain on them for quite some time. How will this fee affect future foreign doctors?
How Visas Work
Before we get into the doctor-specific issues, we probably need a broader discussion about visas. I didn't know much about them prior to writing this post, and most WCIers probably don't either. A visa is a pass to enter a country, such as the United States. People from countries that participate in the Visa Waiver Program (42 countries, mostly European) do not have to get a visa for short tourist or business stays. Here are the countries in the program:
If you're from another country not on that list, you have to get a visa. Even if you're from a VWP country, if you've traveled to Iran, Iraq, Libya, Cuba, North Korea, Somalia, Sudan, or Yemen, you'll also need to get a visa even for a short visit. A visa doesn't guarantee entry. It is a required but not sufficient condition. An immigration officer can still deny you entry. A visa is not a passport either. You always need a passport, but you only sometimes need a visa.
There are more than 180 different types of visas, broadly divided into immigrant visas and non-immigrant visas. Non-immigrant visas need a purpose, such as tourism, work, study, or medical treatment. For our purposes today, we're mostly talking about non-immigrant visas to study and work. Foreigners may study in US medical schools (thus becoming AMGs) just like Americans can study in foreign medical schools (thus becoming IMGs). A foreigner, whether an IMG or AMG, will commonly apply to match into a US residency or fellowship. Since doctors generally get paid better in the US than wherever they came from and since they like it here or have relationships here, they often try to stay permanently after completing their training.
The letter in the name of a visa has a meaning.
- B — Tourist
- F and M — Student
- H and L — Temporary work
- J — Temporary education or cultural exchange
- E — Treaty traders or investors
- O — Athletes and entertainers
- C — Transit through the US
- I — Journalists
There are also various types of visas within each category. For example, here are some H visa categories:
- H-1B — For workers in “specialty occupations” that require a high level of education or specialized skills.
- H-2A — For temporary or seasonal agricultural work.
- H-2B — For temporary or seasonal non-agricultural work.
Typically, foreigners in US medical schools are on an F-1 visa. Residents and fellows can be on an H-1B visa, although I believe most are now on a J-1 visa. Approximately 3% of US medical students are foreigners, but since they're usually on F-1 visas, this new fee does not apply to them. Approximately 6,600 (18%) non-residents matched into residency in 2025. That's a MUCH higher percentage than 3%, and the percentage tends to be highest in primary care residencies. Thirty-nine percent of internal medicine residents are IMGs (although obviously not all of those are non-residents). I couldn't find the exact number of residents and fellows currently on an H-1B visa, but I would love to add it to this post if you have a reliable source.
What Is the Difference Between H-1B and J-1 Visas?
H-1B visas require employer sponsorship, and they are for temporary, specialized workers. But they can be a direct path to a green card (permanent residency). There are annual limitations and caps on H-1B visas unless the employer qualifies for an exemption. Basically, H-1B visas offer more flexibility to stay in the country and work after residency. The Department of Labor oversees H-1B visas.
Downsides of an H-1B visa include:
- Visa is tied to a specific employer, leading to potential job loss or fear of retaliation for complaining
- May also lead to lower wages in some jobs due to a lack of other options (no good BATNA)
- Annual lottery system makes it harder to get the visa in the first place (although I am now told that the lottery doesn't apply to docs)
- Six-year maximum duration
- New one-time visa fee ($100,000)
- Employer costs are higher to run the program, both financially and in time and hassle
- Employers are required to pay the “prevailing wage” (probably an upside for the foreigner)
J-1 visas are often sponsored by organizations like the Educational Commission for Foreign Medical Graduates (ECFMG). They are for educational and cultural exchange, with the expectation that the physician will return to their home country. They require a two-year home residency requirement after completion of the program, or a waiver, to stay in the US longer. More residency programs accept J-1 visas for initial training, and more foreign residents are on J-1s than H-1Bs. You cannot apply for permanent residency while on a J-1, though—that's called “dual intent.” The ECFMG and sponsors oversee J-1 visas.
Downsides of a J-1 visa include:
- Two-year home residency requirement before applying for citizenship
- Strict adherence to approved program (i.e., no moonlighting)
- Poor sponsor oversight leading to poor working conditions, lack of promised training or cultural experience
- Must have health insurance, pay taxes, and avoid welfare
- Some categories have a five-year limit (docs typically get up to seven)
- 24-month ban on repeat participation
- No clinical appointments
- One-time SEVIS fee ($220)
There was a movement a few years ago toward more residents being on H-1Bs than on J-1s, but that pendulum has swung back in the last few years.
More information here:
Landing a Physician Job in the US While on a J-1 Visa
IMG Financial Survival Guide to Residency in the US
What Is This ‘H-1B Spamming' That the Administration Doesn't Like?
H-1B spamming is fraud, gaming the H-1B lottery system. It's when multiple companies (which may all have the same owner) submit numerous lottery registrations for the same foreign worker to increase that worker's odds of selection. It is apparently frequently used by tech staffing and consulting companies. Starting in 2023, multiple applications for the same worker became more common than single applications, so it really is a problem. Presumably, the fee will stop this, although it is likely to have other effects as well.
How Is the New Fee Going to Affect Doctors?
Now that we have some background information, we can speculate about how this is going to affect doctors. First, it's not going to affect residents on a J-1 at all. It's also not going to affect doctors who already have an H-1B visa. We're really talking only about future residents. I suspect the main effect here is that the pendulum between H-1B and J-1 will swing even further toward the J-1 side and that there will be few H-1 B residents at all in a few years. It's just going to be easier for hospitals to do J-1s rather than fork out $100,000 a resident to hire those on H-1B visas.
The downside of training on a J-1, of course, is that you're probably not staying here after training. So, the overall effect is that we will have fewer foreign doctors, and, thus, fewer doctors overall. Our residency programs will be training doctors who are not going to work in the US, at least for a couple of years after training. Certainly, we'll have fewer primary care doctors. It will probably be a little easier for US doctors to match into residency and to find jobs afterward, particularly in primary care. With fewer primary care doctors, those docs may make more money, but access to them will be more limited.
More information here:
How the ‘One Big Beautiful Bill’ Act Will Affect Doctors
Trump Will Allow You to Make Dangerous Moves in Your 401(k), Including Adding Crypto
Trump Accounts — What to Know About This ‘Baby Bonus’ from the One Big Beautiful Bill
What Should I Do If I Am on an H-1B?
Nothing. This fee doesn't apply to you.
What Should I Do If I Want to Get an H-1B to Train in the US?
Wait a few months and let this all get sorted out. We'll need to see if hospitals and residency programs are still willing to pay this fee for you to fill their program. If you have wealth, you could possibly pay for part or all of this fee yourself (although I'm told this is not allowed), making you more attractive to a residency program. Perhaps H-1B fee loan programs will pop up to help, as well. Maybe that isn't the end of the world since many FMGs don't have any student loans.
Is Something in This Post Wrong?
Almost surely. We'll fix it as soon as you point it out or the rules change again. We know many WCIers are on these visas and hope you will help us all to understand this issue better by submitting comments below.
What do you think of this new policy? What are the likely effects to be? What do you think will happen to the medical profession if H-1B workers (or their employers) have to pay this fee?
I dont think the workers are allowed to pay the fee themselves. The fee has to be paid by the employer. The employer is essentially sayng that I can’t find an american worker to fill this job. So it is worth it for me to get a foreign worker despite the fees.
100K is to be paid by the employer.
I think there has to be more clarity in the coming weeks /months.
The residency H1b visa don’t go to the lottery to be “gamed”. Most of the residency H1Bs and post residency H1Bs by not-for-profit hospitals are exempt from the H1B cap and don’t go to the lottery.
The question is – will the White House actually differentiate between the H1B lottery and cap exempt H1Bs and exempt the “cap exempt H1Bs” from this 100K rule or not. We have to wait and see. Until there is a differentiation, yes, J1s will be preferred by residency programs.
You can stay and work in the USA immediately after the J1 residency if you choose an employment in the “J1 waiver program “- underserved and rural areas although I have seen J1waivers in towns like Myrtle Beach depending on the speciality. But the J1 waiver is also done under a H1b and the 100K follows there. The post residency job market will be different for the J1 residency grads, the employers might try to get these docs under lower compensation (cannot change the base pay but other ways to reduce overall comp) to recoup that 100K.
At the end of the day, we need more clarity, advocacy for the sake of our colleagues and patients, and most of all, patience
Thanks for the clarification about the lottery.
$100K to get an attending may be worth it to many employers. Many of them are already paying $50K to a recruiter or as a signing bonus.
Thank you for the clear apolitical explanation (along with the caveats due to uncertainty.) It’s refreshing to learn something without a political spin. As many FMGs end up in rural/less-desirable geographic locations, it will be interesting to see how this plays out with regards to access for patients in those areas.
Thank you for an a -political objective attempt at explaining the situation. It appears that the new directive is an attempt to stack the deck in favor of the native American/naturally born American citizen. I can’t quite conceive of how this is a bad thing.
Well if we had enough qualified American born doctors there would not be a need.
Unfortunately over the last 40 years this country can’t produce enough Doctors, hence the need for foreign trained.
LungDoc, what prompts you to say rural areas of our great country are less desirable? Please flesh that out, maybe including where you are from
I suspect the reason is because fewer people prefer to live in rural areas. They’re less desired on average, but desirable is in the eye of the beholder of course. I don’t want to live in SF or Manhattan, but I also don’t want to live in Kotzebue. None of those are attractive to me compared to a small city or medium sized town in an outdoorsy area.
This summary of visa systems is very impressive! I came here to do a residency on J1 visa 28 years ago not knowing or understanding much of the system. We were strongly discouraged from returning for that 24 months requirement, for various complex reasons. With our oldest children being 7 and 5 and an “American” toddler, we decided to stay here and got a waiver, which is important to note it’s only for undeserved areas and only in primary care specialties (psychiatry was one of them). I stayed at the community mental health center for 10 years (6 on H1B). This worked very well for me and extremely well for the community where I practiced. They never got and will never get another psychiatrist there (maybe an hourly one here and there) and have to do with freshly graduated NPs. This new fee would have made it impossible for that community and many others to get a physician. On the other hand I didn’t know about the spamming, surely they could have addressed that in a smarter way.
Undeserved or more likely underserved?
Thanks for sharing your story as a J-1 and an H1-B.
Underserved of course 🙂
Thanks for catching it, sorry for the typo, it was autocorrect since I had to correct here as well
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Seems not so big a deal for doctors. But 18% foreign docs in our residency is super scary- demonstrates the shortage and will be getting worse.
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Very useful thanks! Did not know all that. One dispelled typo. Under downsides of J1 “ 24 month Ban”. Again thanks. Hope to see you in Vegas.
Fixed.
If you do a j1 waiver , at end of j1 waiver u still need a h1b to work in usa and file for green card . For Indian doctors , this means about 15-20 years of wait time as compared to Pakistani doctors with 3 year wait time to get a green card while on h1b .
The 100 k one time fee is gonna lead to hospitals exploiting the indian doctors further by paying lesser salaries or giving them less desirable shift timings
Overall , the biggest benificiary of this nonsensical fee will be np as many hospitals will accelerate transition to np hospitalists .
I would say most people after doing training on J1 go for a j1 waiver to get an H1B. And this is where i think this policy might hit the most. Even after the waiver is done (3 years) one has to stay on h1 to apply for green card/citizenship. Residencies on the other hand were already turning away from h1. So we might still be training a lot of internationals on j1 but then having a problem keeping them on a H1
The only way for a foreign physician to work in the U.S. regardless what visa they used for residency is H1b. These 18% who matched into residency will go back because there is no path to stay and work as a physician. Most hospitals won’t afford 100k per doctor. They will patch the gap with mid levels as you can’t produce 18% more American physicians overnight. The shortage of physicians will only get worse, the quality of care will go down and it will affect everybody, not just underserved communities.
It looks like physicians might be exempt now. https://m.economictimes.com/nri/work/doctors-may-be-exempt-from-100000-h-1b-visa-fee-report/amp_articleshow/124052403.cms
When the might/may becomes is I’ll update the article. I hope it does though of course.
An increase to make up for that 18% shouldn’t take long with better residency and pay prospects.
You should clarify that the “O” visa is NOT JUST FOR entertainers and athletes. The O visa is for “for individuals with extraordinary ability in the sciences, arts, education, business, or athletics (O-1A and O-1B)”. Physicians and physician/scientists are able to train and work on O visas, with sponsorship from their employer.
Thanks for the clarification.
There is so much about foreign doctors that the public doesn’t know. Most of them have a high level of training abroad, very clinically competent, and come the U.S. to further advance in their training either in residency or fellowship programs. A great number of them also stay for political, cultural or safety reasons, avoiding regional conflict or persecution. Salaries in the U.S. are certainly higher than abroad, but so is the cost of living . Many physicians can live very comfortably abroad, often affording commodities that are quite unaffordable here on an average physician salary (and more so on academic institutions which are largely the most common H-1B sponsors). Furthermore, foreign doctors are more prone than local applicants to remain in academics (given their original interests of coming in the first place) and tend to become great teachers and researchers.
Having now this background, imagine losing a great deal of these new applicants, particularly those who arrive here for fellowship training (almost always H-1B). We do not have enough medical students in the U.S. to fill those jobs, that is the truth. So many subspecialty positions will go unfilled, and those H-1B positions in general practice will be filled by mid levels (PCPs, RNs) that, unfortunately have much less training which will certainly impact patient care. Foreign trained doctors are more often than not assets, and I think they do not see the big picture and how these decisions can be detrimental to the healthcare workforce in the country.
There is also called 3rd party H1b sponsorship where a company hires a foreign national on h1b visa to provide service at client’s location. For physicians, an example would be – Health care company hiring a physician to provide service at contracted hospital where physician is employed by company – not by hospital. In his 1st term – there was significant increase in RFEs (Request for further evidence ) in 3rd party H1b applications – especially in tech and other sectors. Looks like it will come down to that rather than direct h1b sponsorship, Lets see
The foreign dental graduate PASS program for US dental schools will loose students.
There will not be any jobs waiting for these individuals upon graduation due to the 100 k fee.
Some dental schools make up 1/4 of their class with j1 or H1b visa students.
Dental schools will have to pivot and accept more US students or layoff faculty and staff.
The past model of hiring H1B (quasi indentured servitude for US dental school )faculty with a non transferable “teachers” license for a few years will probably come to an end.
Dental schools may close.
Yes, now US students that should’ve been accepted will now get in. Go to any dental mill and all the Dr’s are foreigners working on these employer sponsored visas. Most are working 15 hr days and are stuck fulfilling unrealistic quotas under the fear of being fired and having to return back to their country. I’ve seen it. No US citizen would ever work under these circumstances. Those corporate dental companies will probably just pay themselves back via payroll deduction and these dentists will be living like crop workers 10 to a shed.
Also don’t forget that international dental student tuition at some schools is 2x a US student. That infusion of $$$ for dental programs will diminish.
Great post and research into this. Other than reducing the gaming abuse, I just don’t see what other benefits can truly justify this long term. H-1B is targeting the highly educated graduates. These foreign graduates are generally picked from the cream of the crop among graduates. Most of these students have already spent hundreds of thousands of their own money to get education. It is basically investment out of their own pockets and we are ripe to benefit from their skills as a society. Now they are just going somewhere else with their high credentials to serve the needs of others rather than this nation’s.
It’s worth noting that the H-1B lottery system was changed in FY 2025 to a beneficiary-centric approach in an attempt to combat H-1B fraud. as such, each applicant can only be registered once in the lottery, regardless of how many employers submit a registration on their behalf. The number of registrations has reduced drastically since this change.
There were 780,884 registrations in FY2024 (an all time high). With the beneficiary centric approach, registrations dropped to 479,953 in FY2025 and 358,737 in FY2026.
Interesting that they already seem to have found a solution to the spamming issue but are still pushing this fee as a solution for that.
I know it’s good for you to stay clear from the politics, BUT the real reason, as one can glean from the rhetorics, they are doing this is to reduce legal immigration. Everything else is just a veil.
If the true intent was to just reduced the fraud in the system, 1. They already found one as mentioned above; 2. There are other better solutions as well.
This is a low-hire low-fire economy. College graduates now face difficulty getting jobs. So, the Trump administration has reduced the ability for companies to hire foreigners at lower costs than hiring American citizens. That is the simple fact.
@Patrick, that’s true about tech industry jobs (for now). Not true with medical residency visa sponsorship.
Your argument is strong.
If you read the presidential proclamation, the given rationale for this comes leans much more towards “American workers have been replaced” by this program than “we don’t like the abuse.” They just conflate the two a bunch because they don’t really care or know that there is a distinction. Even if the program had no abuse, American workers would be replaced – that’s how expanding the labor supply works.
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GREAT post–thank you for handling it w/such neutrality and clarity. Was chatgpting the issue myself over the weekend and this is much better.
I have experience with both J1 and H1 B,I believe is the abuse of H1 B visa by some of the companies,initially the numbers of H1 B was 85000 and currently it is close to a million and this is the reason they do selection trough lottory.
In the medical fields that currently we are dealing with shortage of doctors about 50000 mainly in the rural area that american doctors do not like to work there and mainly international doctors are covering these area is going to end up with significant shortage that can affect the life of these class of people
The end result will be less IM/family medicine, Neurology, Psychiatry, Pathology, etc. Docs and more APPs; also less access to doctors in rural areas.
In the meantime, the US trained docs will continue to apply mostly to the more sexy specialties with better income and quality of life.
Agreed! And it will likely drive an unforseen RN shortage in all hospitals as higher paying NP/APP posts are needed in rural/underserved areas to cover for the missing, essential primary care MDs that were filled by H1Bs.
Sure, this may drive up salaries for the remaining physicians. But at what cost? It will be to the detriment of all patients. And will likely overwhelm the remaining doctors and their offices as these patients try to seek the necessary care. This is not a solution. A targeted drive against the health insurance and drug companies that gouge the system, as well as continued protections to Medicaid and Medicare programs, would be a start.
How does the new Visa fee affect the residency match system?
What if someone matches but the future hospital employer refuses to pay this fee?
And what about the new system in underserved areas that sponsor IMGs for limited practice s without requiring a US residency?
As noted in the post, I don’t think residencies are going to select folks on an H1-B unless there is an exemption. I don’t think this is a case of match first, then sort out the consequences. You’re right that this is pretty likely to affect IMGs going to rural areas.
Retired last year as a psychiatrist. I owned a private practice and employed an H1-B doctor. No way I could afford $100K. The hospital and system I worked with worked hard to not run deficits, so $100K/ doctor would have dire consequences. Applying the fee to all fields is ill conceived and will worsen physician shortage.
The summary of the Visa system was good.
The solutions proposed are reasonable if one doesn’t address the underlying problems: 1. US Medical schools do not produce enough medical students nor does post graduate training have enough residency positions; 2. The physicians in rural or underserved areas need higher pay.
There are solutions to both problems. Unfortunately, Medical Schools, Residency Programs, Government, and Private Industry do not want to solve the problems.
Very informative.
It has become very apparent that there are currently not enough physicians in practice or finishing training in the U.S. to sufficiently handle the current workload. Unless more U.S. physicians are trained quickly, this fee structure will just make that problem much worse.
This problem could be at least ameliorated by requiring less documentation and fights to get preauthorizations. The time saved by less of this baloney could be spent on–gasp!–patient care!
$100,000 fee appears to be an entry ticket for mainly rich foreigners, who may or may not be as competitive as some of the poor population.
It is just by stroke of luck that my young life brought me from a small village in India to the United States and subsequently I went to an American medical school. People like me in India today would not have a chance to come to the United States at all. Given that my parents were teachers on a $50 monthly stipend back in 1980s, $100,000 visa cost would just be unimaginable.
The poor of India have a lot of potential and intelligence. There is tremendous motivation amongst poor populations around the world. I think this hundred thousand dollar visa ticket screens out a lot of potential. And makes way for more privileged.
Actually, I think I made a mistake. I just realized from the comments above that the employer pays for the visa, not the applicant.
Regardless, there is a lot of competition And the fee will definitely screen out a lot of good potential.
Had experience being on J1 visa 20 years ago, and it was tough & competitive to find areas that sponsor J1 waivers after residency.
Those places that can sponsor J1 waivers then were rural areas, Indian reservations, Appalachians, inner city & homeless areas, and I think some Jail or Correctional facilities. I’m not sure if things have changed now.
Thanks for this very informative and balanced article. It is rare that I see someone so capable of capturing all of the nuances and details of a topic these days without incorporating their own biases and political spin. It is very well written. Thanks again. Look forward to reading more of your articles!!
Thanks for your kind words and glad you found it helpful.
WCI asked about the numbers of residents and fellows on H1B visas.
According to the AMA, there are 2,669 medical trainees on H1B visas, as compared to 11,230 medical trainees on J-1 visas (https://jamanetwork.com/journals/jama/fullarticle/2839314, Table 7)
One important source of J1 visa waivers is the Department of Veterans Affairs.
I would point out some some specialties are heavily dependent on IMGs. For example, 57% of endocrinology fellowship training positions are filled by IMGs.
Correction: 57% of endocrinology fellows are IMGs, not 57% of positions.
Sounds like “DEI” for US citizens less qualified than the IMGs and other highly qualified International workers in high skill fields they will be replacing.
I lost position due to it being taken by Nepali resident who identified with the UK His training was not good as true of so many