Medicine is an international affair in Maine, and not just because Canada sits nearby.

The Northern Light Health system, which serves 800,000 Mainers, relies on about 100 foreign workers — including physicians, advanced-level nurses, pharmacists, and others – who are in the US via H-1B visas.

While these employees only make up about 1% of Northern Light’s workforce, administrator Paul Bolin, MBA, said they’re a crucial backstop for a mostly rural system that often struggles to find people to hire.

“In some settings, we don’t have other candidates to qualify to fill those roles. So it’s a matter of being able to provide a service or not,” said Bolin, the system’s executive vice president and chief people and administrative officer. Without local doctors, patients may have to travel 2 hours or more for treatment.

This year, this international pipeline is running dry at Northern Light. Instead of the usual four to eight new applicants per year, no one is applying to take positions through H-1B visas.

Even if international workers did apply, the system might not be able to pay the new $100,000 H-1B visa fee imposed by the Trump Administration to hire them.

The fee has alarmed healthcare providers across the country who rely on foreign clinicians to take rural and other hard-to-fill positions.

Hospitals and clinics across the nation are facing the same challenges as they grapple with new visa fees and other challenges on the international hiring front.

Here’s a look at five things to know about the H-1B visa crisis.

1. International Physicians Have a Long History in US

The reliance of the US on foreign physicians dates back more than 60 years to an era of fear about Communism, according to Eram Alam, PhD, associate professor of the History of Science at Harvard University, Cambridge, Massachusetts, and author of the 2025 book“The Care of Foreigners: How Immigrant Physicians Changed US Healthcare.”

In 1965, Congress decided to open the nation’s doors to international doctors and reverse laws that had chilled immigration from Asia, Southern Europe, and Eastern Europe for decades, Alam said.

Amid the Cold War, Asian and African nations became the site of ideological battles between the capitalist West and communist East, she said. Lawmakers viewed immigration as a way to gain ground, she said, while the creation in the 1960s of Medicare and Medicaid spawned new medical jobs to serve millions of people who suddenly had insurance coverage.

For the past six decades, immigrants have made up about a quarter of the US physician workforce, she said.

2. Overall, H-1B Visas Account for Few Healthcare Jobs…

Congress created H-1B visas in 1990 to create a way for immigrants with high levels of skills and education to temporarily enter the US. The visas can be renewed for up to 6 years or longer if applicants are trying to get a green card, which allows permanent residency.

Critics say American employers have overused the visas, turning them into a tool to exploit immigrants and avoiding paying higher wages to Americans.

According to Pew Research, 399,403 new or renewal H-1B applications were approved in 2024, up from 178,803 in 2000. In 2023, just 4.4% of approved applications were for jobs in the medical/health industry. Computer jobs are by far the largest category, accounting for 64.9%.

For the 2024-2025 fiscal year, federal data show that the Cleveland Clinic had the highest number of approved medical H-1B positions (272), followed by St. Jude Children’s (233), Memorial Sloan Kettering (212), Icahn School of Medicine (210) and Montefiore Medical Center (160). None ofthese institutions were willing to answer questions from Medscape Medical News about the status of their H-1B visa programs.

3. …But the Positions Are Highly Concentrated in Rural Areas

While the overall number of H-1B positions in medicine are small, they’re highly concentrated in rural and low-income areas. In fact, a 2025 study of 11,080 H-1B physicians staying in the US in the fiscal year 2023-2024 found that they account for nearly double the percentage of the doctor workforce in rural counties vs urban counties (1.6% vs 0.95%).

And the international physicians make up 2.0% of the workforce in the highest-poverty counties vs 0.54% in the lowest-poverty counties.

“In some communities, they make up 1 in 4, 1 in 3, or even 1 in 2 doctors,” said study co-author Michael Liu, MD, MPhil, a clinical fellow with Beth Israel Deaconess Medical Center and Brigham and Women’s Hospital, Boston.

Citizens Memorial Health Care knows the drill. The system serves 130,000 residents across eight rural counties in southwest Missouri. “Recruitment of physicians in rural areas is extremely difficult,” said Donna Shelby, director of Medical Staff Services and Physician Recruitment, and the system relies heavily on international physicians.

As Shelby told Medscape Medical News, the system’s 86-bed hospital currently employs seven physicians who came through the J-1 visa waiver program, including a pair of interventional cardiologists from Pakistan and India.

The waiver program allows international medical graduates to enter the country to practice in designated shortage areas and not need to return home for a mandatory 2-year period following their medical education. They can then transition to H-1B status.

Now, the Trump Administration’s $100,000 H1-B visa fee — hiked from previous fees ranging from $2,000 to $5,000 — has led the system to temporarily freeze its application process.

4. Trump Just Made a Change, but It May Not Help Much

In late 2025, the Trump Administration made another drastic change to the H-1B visa system. The new policy, which overhauls how visa applicants are approved, will make it easier in some cases for healthcare companies to bring international workers on board.

Previously, the US would only allow for-profit companies to apply for a limited number of H-1B visas each year — 65,000 plus 20,000 for applicants with advanced degrees. Nonprofit and higher-education organizations are exempt from the cap, according to Mark J. Neuberger, JD, a Miami employment attorney who works with healthcare companies.

Too many employers sought visas, pushing the total applications beyond the cap. So the federal government instituted a lottery system in which about 30% of applicants were randomly accepted, Neuberger said.

Now, the White House has modified the lottery system by creating a weighted system that boosts the odds of approval for higher-skilled and higher-paid positions.

The weighting mechanism essentially allows companies to buy multiple “lottery tickets” if positions are higher-paid, Neuberger said. “If you’re in class 4, the highest tier, it’s like four lottery tickets. If you’re in the lowest tier, you only buy one ticket.”

Neuberger said the Trump Administration believes this system will weed out applications for lower-paid jobs such as computer programmers and make more visas available for those in higher-paid positions such as physicians and other clinicians.

Still, companies will have to pay the $100,000 fee, Neuberger said, forcing them to make a cost-benefit analysis about whether hiring a foreign worker is worth the expense. The next annual lottery, he said, is scheduled for April 1.

5. Future of H-1B Visas Remains Uncertain Amid Legal Challenges

In September 2025, dozens of leading medical organizations led by the American Medical Association called upon the secretary of Homeland Security to exempt physicians from the new rule. That didn’t happen.

On the legal front, 20 states in December 2025 sued the Trump administration over the $100,000 annual fees, The New York Times reported. Another federal lawsuit was filed by labor unions, academics, and others.

Meanwhile, a federal appeals court in early January 2026 agreed to move quickly regarding a similar lawsuit filed the US Chamber of Commerce, Reuters reported. A federal judge had earlier rejected the suit.

Hospitals and clinics relying on foreign physicians face another hurdle: On January 14, the Trump Administration announced that it is indefinitely halting all processing of international applicants seeking jobs from 75 countries, The Washington Post reported.

Many of the countries are developing nations in Africa, Asia, the Middle East, the Caribbean, and South America.

India is by far the biggest supplier of H-1B visa workers (71% of those who received new and renewal visas in the fiscal year 2023-2024 were born there), followed by China (11.7%), Philippines (1.3%), Canada (1.1%), and South Korea (1.0%), according to federal data.

It’s not immediately clear how the move to further limit immigration will affect H-1B visas in medicine. However, the list of nations on the no-go list includes Pakistan, Brazil, and Nigeria, which are the eighth, ninth, and 10th largest sources of H-1B visa workers, respectively, each with < 1% of the total.