The H-1B for physicians in training:
history, the $100,000 fee, and what comes next

Two lanes into US training

International medical graduates are not a small corner of American medicine. About one in four practicing US physicians trained abroad¹ — though many are U.S. citizens or permanent residents who need no visa at all; IMG status and visa dependence are different questions. Among the foreign-national physicians who do need sponsorship, one figure gives the scale: a 2025 JAMA analysis counted 11,080 physicians tied to new H-1B labor-condition filings in FY2024 — a number that overcounts actual entrants and includes practicing physicians, because residents and fellows, the authors note, “are more frequently admitted via J-1 visas”². That last point governs everything below: the J-1 is the more common training visa; the H-1B is the strategic alternative. IMGs are also, as Intealth — the parent of the ECFMG, the body that certifies every IMG — told a Pennsylvania rural-health hearing, “more likely than their U.S. counterparts to practice in high-need communities” and “vital to maintaining access to care where it is needed most,” even as the pathway remains “long, complex, and difficult to navigate”³. Foreign-national trainees enter through one of two visa lanes, and the difference between them shapes everything that follows.

The older and more common lane is the J-1 exchange-visitor visa, sponsored for physicians by the ECFMG — whose parent, Intealth, sponsored 15,900 physicians on J-1 visas in 2024 alone, at nearly 770 teaching hospitals³. It is administratively simpler for programs, and a J-2 spouse can generally apply for work authorization — but it carries a heavy string: the two-year home-residency requirement of INA §212(e). Before moving to an H or L visa or a green card, a J-1 physician must either spend two years in their home country or obtain a waiver — most often through a Conrad 30 placement in an underserved area⁴. That waiver route is its own subject, taken up on the primary care career profile.

The other lane is the H-1B specialty-occupation visa. It has no home-residency requirement, it permits “dual intent” (you may pursue a green card while holding it), and it lets a physician move more freely toward permanent status. Its costs are practical and easy to underestimate. The sponsoring program must file and pay for the petition, and an IMG entering clinical training will ordinarily need to have passed all three USMLE Step exams, including Step 3, before the petition is filed (narrow exceptions exist for some teaching and research roles)⁴ — and because Step 3 timing can lag, a program willing to sponsor an H-1B may still be unable to. H-1B status also runs on a six-year clock (extendable once the green-card process is underway), which a three-year residency fits easily but a long residency-plus-fellowship sequence can consume; and an H-4 spouse’s ability to work is far more limited than a J-2’s, and tied to stages of the green-card process. For these reasons the H-1B has long been the harder, more permanent-minded path — chosen by a minority of programs, and by residents with reason to avoid the J-1 string — which is what made the 2025 changes land where they did.

Why most residents never see the lottery

The H-1B is famous for its annual cap and its springtime lottery, in which far more registrations are filed than the 85,000 available numbers. If residency depended on winning that lottery, the physician pipeline would be chaos. It does not, and the reason is a quarter-century-old statute.

The American Competitiveness in the Twenty-First Century Act of 2000 exempted from the H-1B cap any petition filed by an institution of higher education or an affiliated or related nonprofit entity⁵. Many university-based and affiliated-nonprofit teaching hospitals qualify, so the H-1Bs they do file are typically cap-exempt: filed at any time of year, never entering the lottery. But cap exemption is employer- and relationship-specific — it does not follow automatically from being a teaching hospital — and it is a separate matter from whether a program sponsors H-1B at all, which many do not (J-1-only programs are common). So the practical question for an applicant is not whether a hospital might qualify but a sharper one: did this program actually sponsor H-1B residents in the last recruitment cycle or two? Where it does, a resident is insulated from the single most unpredictable feature of the H-1B system.

This is the first of two distinctions that decide who a policy change actually touches. Cap-exemption is about the lottery, and nothing else. It does not, as we are about to see, exempt anyone from the 2025 fee. Keeping the two ideas separate is the whole art of reading H-1B news as a physician.

The $100,000 fee — and who it actually hits

Begin with why it exists, because the fee did not come from nowhere and the case for it deserves a fair hearing. The proclamation’s stated rationale is that the H-1B program, meant to bring in additive, high-skilled workers, has instead been “deliberately exploited to replace, rather than supplement, American workers with lower-paid, lower-skilled labor” — a pattern the administration ties chiefly to the technology sector, citing rising unemployment among recent computer-science graduates and in computer occupations, and employers hiring foreign labor at a discount to American workers. On that logic, a six-figure charge prices abuse out of the program while still letting employers pay for genuinely high-value hires — the “best of the best”⁶. Whether that logic fits a physician in training is a separate question, and one this piece returns to below.

On September 19, 2025, a presidential proclamation, Restriction on Entry of Certain Nonimmigrant Workers, required a $100,000 payment to accompany certain H-1B petitions filed at or after 12:01 a.m. Eastern on September 21, 2025. The proclamation is written as a twelve-month entry restriction, and USCIS issued implementing guidance on October 20, 2025⁷. Read literally it is enormous — more than a junior physician earns in a year. Read carefully, it is narrower than the headline, and the narrowing is what matters to a resident.

The payment attaches to new petitions for a beneficiary who is outside the United States without a valid H-1B visa — that is, to cases that require consular processing abroad. It does not attach to a petition that requests an amendment, change of status, or extension of stay for someone already inside the United States who is maintaining status, nor to anyone holding a currently valid H-1B, nor to petitions filed before the effective date⁷. There is a national-interest exception, but USCIS describes it as reserved for “extraordinarily rare” cases, so no physician should plan around it. One caveat follows from the logic of that protection: it depends on the in-country action actually being granted. If a change of status is denied — or the petition requests consular notification — and the physician must instead be processed at a consulate abroad, the consular route, and its fee, is back in play.

Put those together and the real-world picture is far less dire than the number suggests — for most, but not all. A resident who is already in the United States — on a J-1, on F-1 student status with training authorization, or on an existing H-1B — and who moves to or renews an H-1B by change of status is not charged the fee. That describes the majority of residency and fellowship transitions. The physician the fee genuinely threatens is the one who must enter from abroad on a brand-new H-1B through a consulate: for that person the $100,000 is effectively prohibitive, and it applies no matter how cap-exempt the employer is. It is at least a single hurdle rather than a running one: USCIS states plainly that it is “a one-time fee on submission of a new H-1B petition” and does not change the fees for H-1B renewals⁷, so a physician who clears it once does not pay it again at extension time. “One-time” means once per covered petition, though — not once per physician for life: a later, wholly new petition that again requires consular processing could face it anew.

So does the rationale fit physicians? Here the case is genuinely weaker, and it is fairer to say so than to score points. The abuse the proclamation targets — a domestic surplus of workers undercut by cheaper foreign labor — describes the technology labor market far better than it describes medicine. There is no surplus of American physicians; the country faces a projected shortage, international graduates make up about a quarter of the physician workforce, and they cluster in exactly the rural and underserved communities that struggle most to recruit — as high as one in three or four physicians in some counties¹. A resident is high-skilled by any measure and earns a trainee’s wage not because the market is discounting them but because that is what training pays. The fee, in other words, reaches physicians-in-training largely as collateral rather than as its intended target. On scope, that cuts two ways: most residents already in the United States are insulated, for the change-of-status reasons above, so this is not a wave of six-figure bills hitting current trainees; but the exposure that remains falls on the incoming IMG who must enter from abroad, and on the safety-net and rural systems that lean hardest on international physicians — which is why the AAMC warned the fee will “worsen the nation’s existing workforce shortage” and strain access to care where it is already thinnest¹.

The 2026 court whiplash

The fee has been in court almost from the start, and the two decisions that matter reached opposite conclusions.

First, on December 23, 2025, the US District Court for the District of Columbia upheld the fee in a suit brought by the US Chamber of Commerce and the Association of American Universities, holding that it fell within the broad authority Congress has delegated to the executive to restrict the entry of noncitizens⁸. Then, on June 8, 2026, the US District Court for the District of Massachusetts, in a challenge by a coalition of twenty states, vacated the fee in its entirety — holding that the payment “amounts to a tax,” which a president cannot impose by proclamation, and that its implementation violated the Administrative Procedure Act⁹.

The relief did not last. On June 12, 2026 the government filed a notice of appeal to the First Circuit, and the district court entered a limited administrative stay of its own order while the First Circuit considers the government’s motion to keep the payment in effect during the appeal — so, as of this writing, the $100,000 fee remains operational for affected filings despite having been ruled unlawful. Two federal district courts have now reached conflicting conclusions; that is a real split of authority, but not yet a binding appellate one⁹. The immediate path runs through the First Circuit; further appellate or Supreme Court review is possible but cannot presently be predicted. The only safe planning assumption is that the answer is not yet settled.

The other change: a wage-weighted lottery

Lost in the noise over the fee was a quieter change with a longer reach. In a final rule published December 29, 2025 and effective in early 2026, DHS replaced the random H-1B cap lottery with a wage-weighted selection: a registration offered a Level IV (highest) wage is entered up to four times, a Level III three times, a Level II twice, and a Level I once¹⁰. Higher-paid workers are now several times likelier to be selected.

For physicians the effect is stage-specific. It does not touch cap-exempt residents and fellows, who never enter the lottery. It reaches them later — at the post-training move to a cap-subject employer, such as a private group or a hospital that is not university-affiliated (unless another exemption, such as a J-1 waiver pathway, applies). Depending on the occupation, location, and prevailing-wage determination, an early-career physician’s position may be assigned to a lower wage level and so receive fewer weighted entries than a senior hire — tilting that lottery against the most junior applicants. A companion Department of Labor rulemaking to raise H-1B prevailing-wage levels is also contemplated⁷, which would push the wage floor upward and compound the tilt. A physician mapping a career should treat the cap-exempt training years and the cap-subject job market as two different regimes, and weigh employers accordingly.

Where this is heading

Three currents are worth watching, and none of them has settled.

The fee’s fate is a coin still in the air. With one district court for it and one against, the First Circuit will decide whether a six-figure charge can ride on a proclamation; higher review is possible but cannot be assumed. History counsels humility about predicting the end state: an earlier entry restriction, Proclamation 10052 in 2020, suspended H-1B entry entirely, was extended, and then simply expired in 2021 when a new administration let it lapse¹¹. Entry rules imposed this way have proven both powerful and impermanent.

A physician-specific exemption is being pressed — but is not yet law. Within days of the proclamation the AMA, joined by more than fifty specialty societies, urged the administration to exempt IMG physicians from the fee, and in March 2026 a bipartisan bill — the H-1Bs for the Physicians and Healthcare Workforce Act — was introduced to carve physicians and other health workers out of it entirely¹². The argument is the one Intealth and the AAMC have made throughout: as the AMA’s president put it, “Medicare patients and people in rural and underserved areas already struggle to get the care they need.” Between the courts, this legislation, and the proclamation’s own twelve-month clock, the range of plausible endings is genuinely wide: the proclamation could expire unextended, be extended without a physician carve-out, be struck down or upheld on appeal, be narrowed by broader USCIS exceptions, or be mooted by a physician exemption that Congress may or may not pass. Several of those outcomes spare physicians the fee’s full weight; several do not. Physician relief is an advocacy objective and a possible outcome — not a dependable planning assumption.

The relative pull of J-1 and H-1B is shifting. If the fee survives and bites at consular entry, some programs and graduates will lean back toward the J-1 for the entry step — which trades the fee for the two-year home-residency requirement, and so raises the stakes of the Conrad 30 waiver at exactly the moment that waiver has become a less reliable route into primary care. For anyone whose plan runs through underserved-area service, the two policy stories are now linked.

The mechanics will keep mattering more than the headlines. The through-line of this whole period is that a physician’s exposure to any given change turns on a few structural facts — cap-exempt or cap-subject, change of status or consular entry, J-1 or H-1B — not on the size of the number in the news. A graduate who understands those distinctions can read each new development for what it actually does to their path. That is the durable skill here, because the specifics on this page will change, and the next version of this analysis will have new dates on it.

References

1. Association of American Medical Colleges. (2025). Hospitals and health systems depend on H-1B visa-sponsored physicians. So, what happens now? https://www.aamc.org/news/hospitals-and-health-systems-depend-h-1b-visa-sponsored-physicians-so-what-happens-now About 25% of practicing US physicians are international medical graduates, and they are disproportionately concentrated in rural and underserved communities. Many IMGs are U.S. citizens or permanent residents who need no visa sponsorship; visa dependence is a separate question from IMG status. ↩₁ ↩₂ ↩₃
2. Health care professionals sponsored for H-1B visas in the US. (2025). JAMA. https://jamanetwork.com/journals/jama/fullarticle/2840740 Identified 11,080 physicians tied to certified H-1B Labor Condition Applications in FY2024 (about 0.97% of U.S. physicians). The authors note the filing count may overestimate those who ultimately enter on H-1B, and that it includes practicing physicians — residents and fellows “are more frequently admitted via J-1 visas.” ↩
3. Holmboe, E. (2025, July 16). Written testimony for the Center for Rural Pennsylvania public hearing: International medical graduates and additional licensure pathways. Intealth. https://www.rural.pa.gov/download.cfm?file=Resources/PDFs/news/Holmboe+Testimony-20250709.pdf Intealth, the parent of the ECFMG, sponsored 15,900 physicians on J-1 visas in 2024, training at nearly 770 accredited teaching hospitals. ↩₁ ↩₂
4. American Medical Association. (n.d.). Immigration information for international medical graduates. https://www.ama-assn.org/education/international-medical-education/immigration-information-international-medical-graduates ↩₁ ↩₂
5. American Competitiveness in the Twenty-First Century Act of 2000, Pub. L. No. 106-313, § 103 (2000). https://www.congress.gov/bill/106th-congress/senate-bill/2045 Exempts from the annual H-1B cap petitions by institutions of higher education and their affiliated or related nonprofit entities — the provision that covers most academic teaching hospitals. ↩
6. The White House. (2025, September 19). Restriction on entry of certain nonimmigrant workers [Proclamation]. Federal Register (September 24, 2025). https://www.federalregister.gov/documents/2025/09/24/2025-18601/restriction-on-entry-of-certain-nonimmigrant-workers Stated rationale: the H-1B program, intended for additive high-skilled work, had been “deliberately exploited to replace, rather than supplement, American workers with lower-paid, lower-skilled labor”; the payment is framed as pricing abuse out of the program while still permitting the “best of the best.” The findings cite rising unemployment among recent computer-science graduates and in computer occupations. ↩
7. U.S. Citizenship and Immigration Services. (2025). Presidential proclamation on restriction on entry of certain nonimmigrant workers [Alert]; H-1B FAQ. https://www.uscis.gov/newsroom/alerts/presidential-proclamation-on-restriction-on-entry-of-certain-nonimmigrant-workers USCIS H-1B FAQ (Sept. 21, 2025) and proclamation alert (guidance issued Oct. 20, 2025). The $100,000 payment attaches to new petitions for beneficiaries outside the US and covers both cap-exempt and cap-subject employers; amendments, changes of status, and extensions for those maintaining status inside the US are not subject to it. USCIS states it is “a one-time fee on submission of a new H-1B petition” and does not affect H-1B renewals. ↩₁ ↩₂ ↩₃ ↩₄
8. Chamber of Commerce of the United States v. U.S. Department of Homeland Security, No. 1:25-cv-03675 (D.D.C. Dec. 23, 2025) (upholding the fee). https://www.globalimmigrationblog.com/2025/12/federal-court-upholds-trump-administration-100000-fee-for-certain-h-1b-petitions/ Brought by the US Chamber of Commerce and the Association of American Universities; the court held the fee within the executive’s delegated authority to restrict entry — the opposite conclusion to the later Massachusetts ruling. ↩
9. State of California v. Mullin, No. 1:25-cv-13829-LTS (D. Mass. June 8, 2026) (Sorokin, J.) (order vacating the $100,000 H-1B fee; stayed pending appeal June 12, 2026). https://www.courthousenews.com/wp-content/uploads/2026/06/trump-visa-tax-fee-ruling-sorokin-massachusetts.pdf A coalition of twenty states. The court held the $100,000 payment requirement “amounts to a tax, not a penalty,” exceeding the President’s authority, and set the policy aside under the Administrative Procedure Act (5 U.S.C. § 706(2)(A)). Appeal docketed at the First Circuit, No. 26-01699. ↩₁ ↩₂
10. U.S. Department of Homeland Security. (2025, December 29). Weighted selection process for registrants and petitioners seeking to file cap-subject H-1B petitions [Final rule]. 90 Fed. Reg. 88094. https://www.federalregister.gov/documents/2025/12/29/2025-23853/weighted-selection-process-for-registrants-and-petitioners-seeking-to-file-cap-subject-h-1b Effective on or about February 27, 2026; enters a registration into the cap lottery once for a Level I wage and up to four times for a Level IV wage. Applies to the cap-subject lottery, not to cap-exempt petitions. ↩
11. Proclamation No. 10052, 85 Fed. Reg. 38263 (June 22, 2020) (suspending entry of certain H-1B, H-2B, J, and L nonimmigrants; expired April 1, 2021). https://www.federalregister.gov/documents/2020/06/25/2020-13888/suspension-of-entry-of-immigrants-and-nonimmigrants-who-present-a-risk-to-the-united-states-labor ↩
12. American Medical Association. (2026). AMA applauds bill to exempt physicians from $100,000 H-1B fee [Press release]. https://www.ama-assn.org/press-center/ama-press-releases/ama-applauds-bill-exempt-physicians-100000-h-1b-fee The H-1Bs for the Physicians and Healthcare Workforce Act, introduced March 17, 2026 by Representatives Lawler, Bishop, Salazar, and Clarke, would exempt physicians and other health workers from the fee; the AMA and more than fifty specialty societies have pressed for a physician exemption. ↩

All figures and rules are stated as of July 2026 and are subject to rapid change. This analysis is educational and is not legal or immigration advice; it critiques and explains policy, not any individual, program, or institution. Confirm the current state of the law with a qualified immigration attorney and the government’s own sources before making any career, travel, or filing decision.