What to Know About Fast-Approaching H-1B Visa Changes

What to Know About Fast-Approaching H-1B Visa Changes

Replacing the random H-1B lottery with a weighted selection process could reduce the number of international medical students practicing in underserved areas of the country.

The Department of Homeland Security is replacing the existing random lottery process for H-1B visas with a weighted system that prioritizes higher-paid and higher-skilled workers. (hapabapa/Getty Images)

The H-1B visa program has long served as a key pipeline for international medical graduates and specialized foreign health professionals. This is particularly true in rural and underserved areas, where recent research from the Journal of the American Medical Association revealed a 2-to-1 ratio of H-1B-sponsored physicians in rural versus urban counties, and a ratio of 4-to-1 in poorer versus wealthier counties.

The program was created in 1990 as a temporary visa category to attract highly skilled foreign workers to the U.S. to help address workforce shortages. The program is capped at 65,000 visas annually for positions that require at least a bachelor's degree or its equivalent, with an additional 20,000 visas allocated for individuals who have earned a U.S. master's degree or higher. An H-1B visa is typically valid for up to six years, but it may be extended under certain conditions related to green card eligibility.

Federal Changes

The Department of Homeland Security is replacing the existing random lottery process for H-1B visas with a weighted system that prioritizes higher-paid and higher-skilled workers, effective Feb. 27. This follows a presidential proclamation issued in September last year imposing a $100,000 fee for new H-1B petitions, a change that was recently upheld by the U.S. District Court for the District of Columbia and increases the previous fees, which ranged from $2,000 to $5,000. Rulings in two separate lawsuits, filed in the U.S. District Courts in Northern California and Massachusetts, are pending. Additionally, the American Hospital Association and a number of health care stakeholders are urging the administration to exempt health care professionals from the increased fee.

Projected Health Workforce Challenges

The increased H-1B visa fee, combined with the change in the way visas are awarded, may reduce the number of international medical students and specialized health professionals, a group that currently makes up about 25% of practicing physicians in the U.S., according to the Association of American Medical Colleges. The U.S. faces shortages of over 141,000 physicians across all specialties and more than 245,000 licensed practical nurses by 2038, with acute gaps in primary care, emergency medicine, psychiatry, oral health and rural practice areas.

Nonprofit hospitals and rural facilities may struggle to absorb the $100,000 fee, limiting their ability to recruit foreign clinicians. U.S. graduate medical education programs that rely on international medical graduates, or IMGs, could see reduced participation, exacerbating shortages in certain specialties. In 2025, IMGs accounted for over 25% of the first-year participants in accredited U.S. graduate medical education programs, according to Intealth, a nonprofit organization authorized by the State Department to provide IMGs with ECFMG (Educational Commission for Foreign Medical Graduates) certification.

State-Level Considerations

While immigration policy is generally set at the federal level, state legislators have several policy tools they can use to recruit IMGs to practice within their states, including establishing alternative licensure pathways that waive certain requirements or replace them with lived experience; creating temporary licenses to practice; and funding support programs.

Alternative licensure pathways. Arkansas last year established a pathway for graduates of foreign medical schools to be licensed if a health care provider offers them full-time employment. Hawaii created a pathway for foreign medical school graduates to be licensed as physicians and established a pathway for IMGs to be licensed if they pass certain examinations, possess ECFMG certification and complete two years of postgraduate medical training.

Temporary or limited licenses and permits. Indiana established a limited medical license for individuals who meet certain requirements and hold a medical doctorate or substantially similar degree issued by an international program. Virginiacreated temporary licensure for IMGs for up to two years, after which temporary licensees are eligible for a renewable, restricted license to practice in a federally designated, medically underserved or health professional shortage area.

Support programs for IMGs. Colorado established the International Medical Graduate Assistance Program in 2022 and the Clinical Readiness Program in 2024; both provide direct services, curriculum and assessments for IMGs. Minnesota established the International Medical Graduate Program in 2015 to address barriers and facilitate pathways to practice for IMGs, and appropriated $420,000 in fiscal years 2024 and 2025 to the health care access fund for IMG training grants.

As states address health workforce challenges, particularly among primary and specialty care physicians in rural and underserved areas, they will also need to navigate federal changes to visa programs that have historically facilitated IMG practice in these communities.

Kelsie George is a senior policy specialist in NCSL's Health Program; Lauren Kallins is a senior legislative director in NCSL's State-Federal Affairs Division.