Trump’s H-1B visa fee is a death sentence for US healthcare | Eram Alam

The Trump administration announced last week that every new H-1B visa will now cost $100,000. Framed as a crackdown on Silicon Valley, the policy will devastate American hospitals. Its real casualties will be poor and rural Americans in need of medical care but who will be left with no one to provide it.

One in four US physicians is foreign-trained. Many enter through the H-1B program, disproportionately staffing rural and underserved hospitals where American graduates rarely go. In some facilities, every single doctor is an immigrant. These are the physicians who deliver babies in Mississippi Delta towns, staff emergency rooms in the Dakotas, and run primary care clinics in the Bronx. By raising visa costs from a few thousand dollars to $100,000, the administration is functionally cutting off their pipeline.

The consequences will be immediate and severe. In this year’s residency match, international graduates filled more than 6,600 positions, with the vast majority in internal medicine and family medicine – the unglamorous workhorses of primary care. American graduates consistently avoid these specialties, preferring higher-paying and more prestigious fields. Without immigrant physicians, safety-net hospitals will be unable to fill residency slots, rural areas will lose their only steady doctors, and wait times for basic care will stretch our even further than they already are. The result will not be new jobs for Americans; it will be shuttered clinics and lives lost.

The administration claims that cutting off immigrant doctors will catalyze domestic production of physicians. But training a doctor takes at least a decade, and requires investments in medical education that both major US political parties have consistently refused to make. Since the 1960s, Congress has chosen not to expand medical school and residency capacity in line with population growth, instead treating immigrant doctors as a convenient – and far cheaper – stopgap.

When Medicare was created in 1965, lawmakers agreed to fund graduate medical education precisely because hospitals argued they could not sustain the high cost of residency training on their own. But funding was capped in the 1990s, and despite repeated warnings about looming shortages, Congress has failed to lift those limits. Today, the Association of American Medical Colleges projects a shortfall of up to 86,000 physicians by 2036. That crisis is not the product of immigration policy. It is the predictable result of decades of underinvestment in training the workforce Americans need.

As I show in my forthcoming book, the Care of Foreigners: How Immigrant Physicians Changed US Healthcare, the US has always yoked the fate of immigrant physicians to the health of American patients. After the second world war, when new public insurance programs like Medicare and Medicaid expanded access to care, lawmakers turned to foreign doctors to fill the gaps. The 1965 Hart-Celler Act, passed the same year as Medicare, was explicitly designed to recruit highly trained professionals from abroad. Within a decade, tens of thousands of physicians – overwhelmingly from India and other postcolonial nations – were staffing hospitals across the United States.

This arrangement was hailed as mutually beneficial: the US got the doctors it needed, and immigrant physicians got training and opportunity. But the costs were exported. Countries like India, with far fewer doctors per capita and vastly greater health burdens, lost tens of thousands of their best-trained clinicians. American lawmakers knew it. In 1967, Senator Walter Mondale called it a “national disgrace” that the US was siphoning lifesaving workers from countries “where thousands die daily of disease” in order to staff American hospitals. Yet the practice persisted, institutionalized as a structural feature of US healthcare.

What Donald Trump’s new policy does is break even with this pragmatic, longstanding “America-first” tradition with which the country has long prioritized its own convenience over an honest accounting of its effects on the poorer nations from which it continually extracts value. Instead of using immigration policy to stabilize the system, it weaponizes it for exclusion. The $100,000 fee is not simply a labor market reform. It is a political message: immigrant doctors are expendable, and so are the patients they serve.

The American Medical Association, the American Hospital Association, and 53 leading medical societies have already urged the administration to exempt physicians from the new fee. But carving out exceptions misses the point. Relying on temporary waivers and emergency visas has always been a precarious way to run a healthcare system. Immigrant physicians are not a contingency plan. They are the backbone of American medicine – and they deserve stability, not discretionary exemptions subject to the whims of Kristi Noem, the homeland security secretary.

The deeper crisis at play is not immigration at all. It is America’s refusal to build a sustainable pipeline with which to ensure care for its citizens. For 60 years, policymakers have papered over severe underinvestment in medical education and poor rural and urban communities by exploiting immigrant labor. Now, instead of repairing that rotten foundation, the administration is simply dynamiting the patchwork that has kept the system functional. Wealthy hospitals in big cities may find ways to absorb the costs. Rural and safety-net hospitals cannot. Patients in those communities – disproportionately poor, rural, and minority – will be the ones left sacrificed in service of Trump’s indulgence for dramatic, nonsensical proclamations without accounting for their very real consequences for American communities.

The lesson of this moment should not be that immigrant doctors need another exception. It is that Americans cannot afford to keep treating healthcare labor as a disposable commodity, imported when convenient and scapegoated when politically expedient. What we need is structural reform: expanding medical school and residency capacity, investing in primary care, and ensuring that immigrant doctors who already sustain the system have a predictable, efficient and permanent route to practice.

Immigrant physicians have long been America’s safety net. To slam the door on them now, without fixing the underlying shortages, is more than shortsighted. It is a policy of exclusion disguised as reform – and it will cost lives. America first, in this case, will make Americans die.

• Eram Alam is a historian of medicine and migration in the department of the history of science at Harvard University. She is the author of the Care of Foreigners: How Immigrant Physicians Changed US Healthcare, forthcoming from Johns Hopkins University Press in October 2025