April 28, 2026
Bethany Kozma
Director of Global Affairs (OGA)
Department of Health and Human Services
330 C St SW
Washington, DC 20201
HHS Exchange Visitor Program, Executive Secretary
c/o Michael Berry
HRSA / Bureau of Health Workforce
Parklawn Building, Room 11W-56
5600 Fishers Lane
Rockville, MD 20857
Dear Ms. Kozma and Mr. Berry:
On behalf of the Society of Hospital Medicine (SHM) and the nation’s more than 50,000 hospitalists, we write to urge immediate action to address the administrative backlog currently affecting the Department of Health and Human Services (HHS) J-1 Exchange Visitor Waiver Program. This delay poses a direct and urgent threat to the care of hospitalized patients in rural and underserved communities across the United States.
Hospitalists — physicians who specialize in the care of hospitalized patients — are the backbone of inpatient medicine in rural hospitals. Hospitalists manage acute illness, coordinate care across specialties, and often provide comprehensive care at facilities that cannot recruit or retain other specialists. International Medical Graduates (IMGs) practicing on J-1 visas are a critical component of this workforce. Physicians trained outside the U.S. account for 23 percent of licensed physicians in the U.S., and in 2021, approximately 64 percent practiced in Medically Underserved Areas or Health Professional Shortage Areas (HPSAs), with nearly 46 percent serving in rural settings. SHM members have reported that J-1 waiver applicants in the current backlog have secured hospitalist positions — specifically, but not limited to, hospitals in Michigan, Indiana, Kentucky, Virginia, Wisconsin, Maryland, South Carolina, Missouri, Pennsylvania, New York, and Texas. These are all communities facing the greatest need.
Applications submitted as far back as October 2025 remain stalled and physicians with contractually obligated July 1 start dates are now at serious risk of being unable to begin serving patients in their new communities. Hospitals in underserved areas that have recruited and contracted with these physicians also face a further exacerbation of physician shortages and harm to their ability to meet patient needs.
This crisis is further compounded by the new $100,000 H-1B filing fee that applies when a physician is required to file from outside the United States. If the waiver delay causes a physician’s J-1 status to expire before their H-1B transition is completed within the U.S., that physician must depart the country and face this prohibitive fee — effectively ending any realistic prospect of returning to serve the community that has been counting on them. This is not a hypothetical risk; it is the situation now confronting graduating resident physicians who trained in the United States and specifically desire to care for patients in high need, rural and underserved areas.
The Health Resources and Services Administration estimates that over 34,400 practitioners are needed to eliminate existing shortage areas, and the AAMC has projected a need for up to 202,800 additional physicians to meet current demand. Rural hospitals, in particular, depend on the HHS Exchange Visitor Program as one of the few reliable pipelines for inpatient physician staffing. Every day this backlog persists is a day that hospitalized patients in these communities face greater risk.
SHM respectfully urges HHS to take immediate emergency steps to process physician applications with 2026 start dates and provide transparent communication to affected applicants and their employers regarding expected timelines. These steps are needed to protect the patients and communities these physicians are committed to serving.
The U.S. healthcare workforce and the rural and underserved patients who depend on it cannot afford further delay. We thank you for your urgent attention to this issue and stand ready to work with you toward a timely resolution.
Sincerely,
Efrén C. Manjarrez, MD, FACP, SFHM
President
Society of Hospital Medicine