Immigration Challenges Facing The U.S. Healthcare Workforce

The U.S. healthcare system continues to experience severe workforce shortages, particularly in underserved areas and rural communities.

A significant portion of the healthcare workforce has historically relied on foreign-born professionals, including physicians, nurses, and other vital positions. However, recent immigration policy developments and proposals may limit access to these essential workers and further complicate long-term workforce planning.

According to the American Medical Association, almost 25 percent of practicing physicians in the United States are international medical graduates (IMGs). These professionals, many of whom arrive on J-1 exchange visas, have historically filled critical shortages in primary care and specialty medicine. Further, approximately 1 million noncitizens provide essential care in hospitals and long-term care facilities, as well as in home health settings, according to the Journal of the American Medical Association (JAMA) Network.

Proposed elimination of Duration of Status (D/S)

One of the most pressing concerns for medical institutions and hospitals is the Department of Homeland Security's (DHS) proposal to eliminate "Duration of Status" (D/S) for certain nonimmigrant visa classifications, including the J-1 category, the status that the majority of International Medical Graduates (IMGs) come to the U.S. on for residency and fellowship programs .

Currently, IMG physicians with J-1 visas are admitted for the duration of their program, as noted in their DS-2019, issued by their Graduate Medical Education (GME) sponsor, without a fixed end date. As GME programs generally last one year, the DS-2019 is usually issued for one year and then renewed, with a new DS-2019 issued by the GME sponsor, upon renewal of contracts and appointments.

The physician is not currently required to formally extend their J-1 status through USCIS as the updated DS-2019 from their program director, combined with their admission for "Duration of Status," effectively does that for them. However, the proposed change would impose fixed expiration dates on their admission, matching the length of their program on the DS-2019. Hence, the physician will now be required to file extensions of status after a fixed term.

This change will inject financial hurdles, administrative burdens, and immigration challenges for physicians and GME programs, which will, as a result, exacerbate the nation's physician shortage. A proscribed end date will require the physician to timely file extensions of their J-1 status, which is a significant shift in responsibility to the J-1 physician versus the GME sponsor that currently and historically updates the physician's status through a new DS-2019 form.

If the physician does not timely file their I-539 extension, the physician's immigration status will be in jeopardy. They and their J-2 family members will also be subject to current processing times for I-539 extensions of status, which may be as long as 16-18 months (at the time of this publication) and means they may have a gap in status and work authorization until the extension is approved. One major concern is that this will cause delays and disruption to their training, which not only impacts the physician's ability to provide clinical duties and for credentialing, but also the GME program.

Further, these extensions would likely need to be filed on an annual basis, depending on the J-1 physician's residency or fellowship contract defining the length of their program. Programs which operate on academic year cycles starting on July 1 will likely see mismatches: contracts and appointments are usually finalized only a few months before July 1, whereas USCIS extension applications must be submitted before the physician's J-1 expiration, creating a risk of gaps or rushed filings for the physician.

The proposed rule is facing strong opposition in the healthcare industry as it is going to significantly change how J-1 IMGs maintain legal status in the U.S. and how GME offices handle contract/program renewals. The American Hospital Association (AHA) issued a public letter opposing the rule, given the additional difficulties imposed on healthcare employers. Similarly, a joint coalition of healthcare organizations including the American Medical Association (AMA), Association of American Medical Colleges, Physicians for Healthcare Access, and others issued a letter opposing the rule. The proposed regulation passed the "notice and comment" period on October 27 and, once issued as a final rule, may go into effect 30 days after publication.

If this rule goes into effect, J-1 visa holders should plan to proactively file for extensions of their status as soon as possible, given the lengthened processing delays.

Healthcare institutions that host IMGs in residency or fellowship programs or research scholars, should prepare proactively for training disruptions, increased compliance burdens, and risk of accidental status violations that can affect the physician's future eligibility for visas.

For example, program directors and GME offices may want to consider building a calendar that triggers I-539 extension filing windows for their IMGs, allowing time for contract finalization and USCIS processing; updating onboarding/credentialing policies to require proof of timely-filed extensions before clinical work or payroll begins; educating their J-1 IMGs routinely and being clear as to their responsibilities in this new process; coordinating with legal counsel and/or program designated sponsor on a standard process for extension filings; and budgeting for added administrative/legal costs for USCIS filings (or determining a policy for who will be responsible for these added costs).

New $100,000 fee for initial H-1B visas

Another significant new policy involves the introduction, via Presidential Proclamation, of a $100,000 supplemental filing fee for new H-1B petitions. This new fee applies to all new H-1B petitions submitted after 12:01 am ET on September 21, 2025, for beneficiaries who are outside the U.S. at the time of filing, or for petitions that request consular notification, port of entry notification, or pre-flight inspection.

It does not apply to H-1B petitions filed before this date, nor petitions for extension or amendment of H-1B status, nor any change of status petitions to H-1B from within the United States. While the most recent USCIS guidance does not specify how H-1B change of employer filings are affected, they have not been impacted in practice.

Unfortunately, there is no broad exception to this rule for "cap-exempt" employers, namely hospital systems and nonprofits. The White House indicated to Bloomberg News in late September that physicians may receive a broad-based exemption from the fee, but an industry-wide exception has not yet materialized.

There is still some uncertainty around the implementation of this fee, and it is also facing multiple legal challenges in federal court, including by the U.S. Chamber of Commerce. The fee is creating a substantial financial barrier for hospitals and healthcare systems that depend on H-1B professionals, including physicians, pharmacists, therapists, and technologists, many of which are professions already experiencing significant shortages. Particularly in rural or nonprofit healthcare settings with limited budgets, such a fee is discouraging employers from pursuing H-1B sponsorship, even when facing critical staffing needs.

Current guidance (as of October 2025) confirms that a limited exception is available for roles that are in the national interest. However, this exception may be narrowly-tailored in practice, as it is intended to only apply in "extraordinarily rare circumstances," where: (1) the worker's presence is in the national interest; (2) no American worker is available to fulfill the offered H-1B role; (3) the worker does not pose a threat to national security; and (4) applying the fee to the petitioning employer would undermine the national interest.

Physicians — especially those who have received a waiver under INA214(l) to work in underserved areas — and other allied healthcare workers should theoretically qualify for this National Interest Exception based on the healthcare industry being a critical infrastructure in the U.S., the fact that their work benefits the health and welfare of U.S. citizens, and the growing shortages of healthcare professions.

For example, the HRSA states in its most recent report that "across all physician specialties in the United States, there is a projected shortage of 187,130 full-time equivalent physicians in 2037. Nonmetro areas will experience greater shortages of physicians than metro areas." Suggested evidence may include data on the patient-to-physician ratios in the area where the physician will be working, and recruitment efforts.

While the tailored National Interest Exception may enable healthcare institutions to continue sponsoring H-1B workers without paying the $100,000 fee, this Proclamation has a chilling effect on hiring much-needed healthcare workers. Healthcare workers and providers who could be affected by the fee should contact experienced immigration counsel to discuss available options.

Changes to shortage area designations

The Health Resources and Services Administration (HRSA) is in the process of revising how it designates Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs).

The HRSA Modernization Project aims to standardize and update the data sources and methods used to determine shortage area eligibility. This "modernization process" could result in the removal of some previously designated areas, likely by July 2026.

This means that healthcare facilities in affected regions may lose eligibility for programs that depend on shortage designations, including the Conrad 30 J-1 waiver program. This program, along with other Intra Government (IGA) Agency programs, allows J-1 physicians to waive the two-year home residency requirement imposed by the J-1 visas physicians hold during residency and/or fellowship.

Through the waiver program, J-1 visa holders can work in the United States after completing their medical training, provided they serve in a shortage area for a three-year period. Similarly, physicians may apply for a Physician National Interest Waiver (PNIW), a green card pathway specifically carved out for physicians who make the same commitment to an underserved area for a period of five years. The J-1 waiver and PNIW programs, which hinge on HPSA and MUA designations, are vital to strengthening the U.S. healthcare system by addressing critical physician shortages in rural and underserved communities. These programs allow highly-trained IMG physicians to continue practicing in the U.S. (where they likely completed training), ensuring that patients in high-need areas have consistent access to quality care.

Reducing the number of HPSAs will limit the options for physicians for employment in the United States after completing their medical training, either through the J-1 waiver or PNIW pathways. Designation turnover is also causing timing conflicts and recruitment disruptions because some agencies that process the waiver will not consider a worksite that is under "proposed for withdrawal" status, whereas others will consider the worksite until the HPSA designation is official changed to withdrawn.

Given that hospital systems and healthcare employers typically hire in the preceding fall (now) for attending positions with fellows and residents who are completing their programs in the following spring, some employers and physicians currently do not have certainty if the physician will still be able to start during the following cycle, dependent on if the worksite designation changes between now and the start date.

While designation changes won't impact the physicians with an already approved J-1 waiver, hospitals and other practices that rely on J-1 waiver physicians could be left without this key recruitment pathway. Practices and physicians should consider refining their recruitment for the upcoming cycle and submitting waiver applications as early as possible for currently designated and eligible worksites.

Without an eligible worksite for the J-1 waiver, physicians and their employers will likely need to consider alternative strategies, such as the O-1 extraordinary ability for temporary status, and/or alternative employment-based green card strategies such as the EB-1 extraordinary ability or outstanding researcher categories.

LEARN MORE: What is the J-1 waiver for physicians? Key details, agencies involved and what every noncitizen doctor needs to know

Possible changes to the PERM process

In addition to nonimmigrant visa concerns, pressure is also being felt in the permanent labor certification (PERM) recruitment process, which is required for many employment-based green card categories. Adjustments in practice are being felt widely and prompted by the DOJ's November 2023 settlement with Apple Inc., alongside the rapid progression of technological advancements in recruitment and application processes.

Employers must show that their recruitment efforts for PERM positions involved a "good faith effort" to reach potentially qualified applicants, including U.S. workers. An underlying issue in the Apple case was whether Apple engaged in good faith recruitment efforts since its PERM-based recruitment required mail-in applications, whereas the non-PERM recruitment allowed for email or online applications. The DOJ's Immigrant and Employee Rights (IER) Section ultimately perceived this practice as not adhering to the standards of conducting recruitment efforts in good faith.

The Apple settlement with the IER highlights the importance of adhering to both PERM regulations and antidiscrimination laws enforced by the IER. For employers, including in industries like healthcare, this underscores the need to not only comply with the explicit requirements of the PERM process but also to proactively ensure that their recruitment practices do not inadvertently disadvantage U.S. workers.

Employers should engage legal counsel to review and possibly realign their recruitment processes, ensuring that PERM and non-PERM procedures are consistent and equitable. This involves considering all applications fairly, regardless of the submission method, and integrating internal applications into the recruitment process. Additionally, when outsourcing recruitment to third-party agencies, employers should diligently audit these partners to ensure compliance with both PERM rules and anti-discrimination laws.

Furthermore, employers in all industries are encountering unprecedented challenges due to the surge in applicant volumes driven by web scraping and AI-assisted applications. Despite these technological advances, employers must adhere to existing compliance obligations, ensuring that job opportunities are accessible to U.S. workers and documenting recruitment efforts meticulously. The practice of job boards and aggregators scraping postings has led to inflated application volumes in response to PERM advertisements.

Additionally, AI-generated applications contribute to increased volume. To manage these challenges, employers should consider controlling the distribution of job postings and configuring them to prevent unintended scraping. Structured business processes, like centralizing applications through an Applicant Tracking System (ATS) can also help handle high applicant volumes effectively. While AI tools can assist with screening, employers must still address risks of hidden bias and ensure human oversight in AI decisions, maintaining transparency and compliance with PERM requirements.

Finally, processing delays have already extended PERM timelines, causing continued frustration for employers and foreign-born healthcare workers working under temporary status. Where possible, healthcare workers and their employers should consider alternative green card pathways that bypass the lengthy and costly PERM process, such as the Physician National Interest Waiver, the National Interest Waiver, or the EB-1 immigrant visa for individuals of extraordinary ability or outstanding professors/researchers.

Limited visa options for registered nurses

Registered nurses continue to face limited immigration pathways. Most RN positions do not qualify as a "specialty occupation" under the H-1B visa criteria as they do not traditionally require a minimum of a bachelor's degree as required under the H-1B program. Outside of the H-1B, there are very limited nonimmigrant work visa options for nurses.

While some healthcare systems pursue immigrant visas (green cards) for foreign-trained nurses through Schedule A, Group I designations, retrogressed visa bulletin dates result in multi-year waits. Unfortunately, this multi-year wait is not realistic for healthcare systems desperate for nurses.

That said, supervisory or advanced practice nursing positions such as Certified Registered Nurse Anesthetists (CRNAs) or Nurse Practitioners (NPs) traditionally require the minimum of a bachelor's degree and are therefore eligible for the H-1B. There are also citizenship-specific visa options for nursing positions, such as the TN visa for Canadian or Mexican citizens.

According to the U.S. Bureau of Labor Statistics, employment of registered nurses is projected to grow about 5 percent from 2024-2034. This translates to more than 189,000 job openings each year, on average, driven by retirements and nurses leaving the industry as well as the country's aging population.

Despite this critical need, there is no catchall short-term visa solution for most international nurses. This immigration gap continues to limit healthcare practices' ability to scale nursing teams and fill vital open roles.

Temporary Protected Status (TPS) program rollbacks

Temporary Protected Status (TPS) has provided work authorization to nationals of certain countries affected by armed conflict, environmental disasters, or other extraordinary conditions.

More than 160,000 employees in the healthcare sector are foreign nationals from countries that at one time qualified for TPS, according to the Journal of the American Medical Association (JAMA) Network.

However, the government has moved to terminate TPS designations for nearly all countries, including Venezuela, Afghanistan, Honduras, Nepal, and Nicaragua.

While litigation has delayed the implementation of some of these terminations, the phase-out of TPS for these populations may impact tens of thousands of healthcare workers.

Without another path to permanent residence or temporary work authorization, these individuals could lose the legal ability to continue working. The loss of TPS-based workers will exacerbate workforce shortages in nursing, long-term care, and support services, sectors already struggling to retain sufficient staff.

Healthcare employers who currently employ TPS recipients should consult with experienced immigration counsel and closely monitor DHS announcements regarding re-registration deadlines, redesignation decisions, as well as litigation outcomes.

Where possible, exploring alternative immigration strategies, such as family- or employment-based petitions, may offer a path forward for some affected employees.

FURTHER READING: State of humanitarian immigration and what alternative options may be available

Conclusion

Together, these proposed changes and procedural developments create a more uncertain landscape for healthcare workforce planning, but one thing for certain is that, with these changes and uncertainty, healthcare industries should prepare and plan as proactively as possible in collaboration with legal counsel. Healthcare employers and administrators should monitor developments closely, review their current workforce composition, and coordinate with immigration counsel to ensure timely filings and compliance.

Immigration has long served as a key tool for addressing gaps in the U.S. healthcare system, especially in rural and underserved areas. Policy shifts that increase costs, reduce flexibility, or restrict access to qualified foreign professionals will unfortunately undermine efforts to stabilize and grow the healthcare workforce. Immigration continues to play a critical role in healthcare delivery, and maintaining access to global talent remains a pressing operational concern for hospitals, clinics, long-term care providers, and more.

The attorneys in Garfinkel Immigration Law Firm's Healthcare Specialty Practice Group continue to monitor the latest updates and developments closely and will continue to alert clients as circumstances evolve and more information becomes available.