In 1965, Congress passed the bill that created Medicare. It was implemented in 1966, and suddenly 20 million previously medically uninsured seniors had access to health care. The need for a larger physician workforce was obvious, and in an uncharacteristically timely fashion, Congress, for the first time, created a route for physicians who were graduates of foreign medical schools to train and practice medicine in the United States.
To qualify, International Medical Graduates (IMGs, formerly referred to as Foreign Medical Graduates) undergo a rigorous process that includes passing all exams for licensure that American grads take, plus a test to demonstrate proficiency in English.
AND…a visa to work in the United States. IMGs have traditionally used two types non-immigrant visas to qualify for employment. The J-1 visa allows for training in the US for a maximum of seven years, and then requires the holders to return to their countries of origin for two years. One way for physicians to extend this time line is to promise, after completion of training, to serve in a medically underserved area for two years, usually a physician poor rural area. Exceptions can also be made to the two year rule for hardship cases, the most common of which is marriage to a US citizen.
The H-1B visa is more flexible, having no home residency requirement. The government caps the number of foreigners who can qualify for this status, and the people that use this route most are in technology. Because of the small number of H-1Bs available, the great majority of foreign physicians have traditionally used the J-1. Currently, the cap for this method of getting the more desirable H-1B is about 65,000, although arcane rules increase this number by another 20,000 (for instance, earning a masters degree in a US program). The increased cap numbers has resulted in IMGs in residency programs currently using H-1Bs about half the time.
The Catch of H-1Bs
To qualify for an H-1B, a foreigner must have a sponsor, and this sponsor pays the government a fee. At $5,000, this amount was nominal and not an impediment to applying for this visa. However, the current administration, in September of 2025, raised the fee to $100,000. The rationale for this action was that foreigners, mostly in the tech industries, were allegedly taking jobs away from Americans, and that the new fee would open up more jobs for Americans. I do not know what the effect of this new rule is on the tech industry, but I do know that the effect on the physician workforce in the US can be profound.
Stats on the Physician Workforce
Of the approximately 1.1 million physicians who are licensed and practicing in the US, somewhere between 25 and 30 percent have foreign medical degrees. They are overrepresented in medically underserved areas, providing access to medical care that would not exist if the healthcare system depended on American grads to choose to practice in, say, rural areas.
24 percent of resident physicians (doctors, including IMGs, who are taking required advanced training)–almost 10,000, training in the US are IMGs. Many of the sponsoring hospitals are dependent on this person power resource, as the residents provide care for underserved populations while in the residencies. They learn by doing. The $100,000 fee for these hospitals, already on the margins of viability, is simply untenable.
Medical educators scrambled to reverse this potentially catastrophic new fee, and in June of this year (2026), a court struck down the new fee, finding that only Congress could alter it. Residency directors, and foreign trainees, not to mention patients whose access to medical care is marginal anyway, got a reprieve, but new rules, and additional fees on H-1B visas in general are making hiring of IMGs more difficult.
Unintended Consequences
A policy change intended to mainly target employment in the tech industry has had potentially enormous, and apparently unintended, impact on healthcare. Such cavalier rule making in healthcare has resulted in many adverse consequences. The de facto campaign against vaccines has resulted in thousands of cases of measles, a disease that virtually did not exist in the US a few years ago. The military lifted the requirement for flu vaccines, and 20,000 soldiers came down with flu (this policy has been reversed). Just today (July 16, 2026), I heard that Secretary Hegseth has ordered all military personnel to get testosterone levels drawn. What will be done with these tests is unknown, but the questions about the wisdom of this order are legion.
In regard to making rules that affect the physician workforce, thoughtless changes are like playing with fire. With regard to immigration, I implore the powers-that-be to BE CAREFUL.