SHM Signs on to Joint Letter to DHS Expressing Concerns About H-1B Cap Subject Application Fee

Submitted electronically

RE: Fee for Certain H-1B Petitions Notice of Proposed Rulemaking; RIN 1615-AD20; DHS Docket No. USCIS-2026-0298

Dear Secretary Mullin and Director Edlow,

On behalf of the undersigned national physician, medical specialty, health care, and patient access organizations, we write to express concern regarding the Department of Homeland Security’s recent proposed rule, Fee for Certain H-1B Petitions, which would impose a $103,265 fee for all H-1B cap-subject petitions, including those eligible for the advanced degree exemption, and how it may impact America’s health care workforce. While we appreciate the Administration’s mandate to protect national security and administer the nation’s immigration system, we urge the Department to recognize physicians and dentists as professionals whose entry and continued employment in the United States is inherently in the national interest and to establish a permanent national medical interest exemption applicable regardless of whether an H-1B petition is cap-subject or cap-exempt. Though this proposed rule is limited to a new fee on cap-subject H-1B petitions, it underscores a broader challenge facing the health care workforce: immigration-related restrictions and costs continue to create barriers to recruiting and retaining those who are critical to maintaining access to care in communities across the nation.

America’s health care workforce depends heavily on internationally born and trained physicians and dentists. International medical graduates (IMGs) comprise nearly one-quarter of all practicing physicians in the U.S. and account for nearly one-third of physicians practicing in family medicine, internal medicine, and pediatrics.¹

More than 11,000 physicians currently practice in the U.S. on H-1B visas,² providing essential care in primary care, psychiatry, and other specialties facing persistent workforce shortages. These physicians disproportionately serve rural, underserved, and vulnerable communities. Rural counties rely on H-1B physicians at nearly twice the rate of urban counties, while the highest-poverty counties rely on H-1B physicians at nearly four times the rate of the wealthiest counties.³

Internationally trained physicians are substantially more likely to practice in Health Professional Shortage Areas (HPSAs), Medically Underserved Areas (MUAs), and rural communities where physician shortages are most severe.⁴

The importance of these physicians will only increase in the years ahead. The U.S. already faces significant physician workforce shortages, with projections estimating a shortage of nearly 86,000 physicians within the next decade.⁵

U.S. medical schools do not currently produce enough physicians to meet the nation’s future workforce needs. At the same time, demand for health care services continues to grow as the population ages and many currently practicing physicians approach retirement. In many communities, particularly rural and underserved areas, internationally born and trained physicians are not simply part of the workforce; they are the workforce.

For this reason, we are concerned by policies that create new barriers to recruiting and retaining physicians and dentists. The Department’s proposed rule would establish a new fee of more than $103,000 for cap-subject H-1B petitions. Although many health care employers are cap-exempt and would not be directly subject to this fee, those practicing in community-based settings, independently owned practices, rural hospitals, safety-net institutions, and other non-cap-exempt environments could face significant recruitment obstacles, and the impact of such costs cannot be viewed in isolation. Hospitals, clinics, and physician practices across the country already face mounting workforce pressures, escalating operating expenses, and ongoing challenges recruiting physicians into lower-margin specialties such as family medicine, general internal medicine, pediatrics, psychiatry, and dentistry. Additional immigration-related costs and administrative burdens risk discouraging recruitment precisely where shortages are most acute.

Importantly, the health care workforce presents a fundamentally different policy consideration than many other sectors utilizing the H-1B program. Physicians and dentists undergo years of specialized education, residency training, and licensure requirements before entering practice. They provide services that directly affect the health and safety of the American public. Delays in recruitment and onboarding translate specifically into longer patient wait times, reduced access to care, increased strain on emergency departments, and diminished health outcomes in already vulnerable communities.

Moreover, the United States’ health care workforce challenges extend beyond fees alone. As our organizations have previously communicated to the Department, physicians, dentists, residents, fellows, researchers, and medical trainees continue to encounter visa processing delays and other administrative barriers that disrupt patient care and training pipelines. Even short delays can leave residency positions unfilled, postpone the arrival of needed physicians, and create significant disruptions for patients and health care systems. The Department already possesses the authority to recognize professions whose entry and employment serve the national interest. Previous coalition correspondence has highlighted that authority and urged DHS to determine that physicians, including practicing physicians and dentists, residents, fellows, researchers, and trainees qualify for such treatment. We continue to believe that physician services clearly meet any reasonable standard for national interest consideration.

Our organizations believe the proposed rule clearly demonstrates that the Department has the ability to distinguish between categories of H-1B petitions when unique policy considerations warrant different treatment. We respectfully submit that physicians and dentists merit similar recognition because of their indispensable role in safeguarding public health and maintaining access to care. Accordingly, we urge DHS to:

• Recognize physicians, dentists, and trainees as serving a permanent national medical interest warranting special consideration under H-1B policies.
• Establish a permanent exemption for physicians and dentists from H-1B-related fees and restrictions, regardless of whether the petition is cap-subject or cap-exempt.

• Continue efforts to improve visa processing efficiency and reduce administrative barriers affecting physicians, residents, fellows, researchers, and other medical professionals.
• Work with Congress to advance durable legislative solutions, including the H-1Bs for the Physicians and Healthcare Workforce Act (H.R. 7961).

Every physician who enters practice represents an investment that pays dividends for decades through healthier, stronger communities and greater economic productivity, and those born and educated abroad are indispensable members of the American health care workforce and economy. They care for patients in communities where shortages are most severe, strengthen primary care capacity, support rural hospitals and safety-net providers, create jobs, and improve access to care for millions of Americans. Policies that unnecessarily impede their recruitment and retention ultimately harm patients. If we are serious about strengthening our health care workforce and improving access to care, we should not erect new barriers for qualified individuals willing to dedicate their lives to caring for others.

We appreciate the Department’s consideration of these comments and its ongoing efforts to balance national security priorities with the operational needs of the U.S. health care system. We look forward to working with DHS to ensure that immigration policies support, rather than undermine, qualified physicians and dentists being able to enter, remain, and continue serving patients in the U.S. without unnecessary fees or delays. If you have any questions, please contact David Tully with the American Academy of Family Physicians at dtully@aafp.org.

Sincerely,

American Academy of Family Physicians
Ambulatory Surgery Center Association
American Academy of Neurology
American Academy of Pediatrics
American Association of Colleges of Osteopathic Medicine
American Association of Neuromuscular & Electrodiagnostic Medicine
American Association of Orthopaedic Surgeons
American Brain Coalition
American Clinical Neurophysiology Society
American College of Cardiology
American College of Emergency Physicians
American College of Obstetricians & Gynecologists
American College of Osteopathic Obstetricians and Gynecologists
American College of Osteopathic Family Physicians
American College of Physicians
American College of Radiology
American College of Rheumatology
American Gastroenterological Association
American Medical Association
American Osteopathic Association
American Psychiatric Association
American Society for Clinical Pathology
American Society of Echocardiography
American Society of Hematology
American Society of Nephrology
American Society of Nuclear Cardiology
American Society of Pediatric Nephrology
Anxiety and Depression Association of America
Association for Advancing Physician and Provider Recruitment
Association of Academic Leaders of Neurology (formerly AUPN)
Association of Departments of Family Medicine
Association of Family Medicine Residency Directors
Benign Essential Blepharospasm Research Foundation
College of American Pathologists
International Bipolar Foundation
NAPCRG
National Association of Community Health Centers
National Rural Health Association
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
Parkinson’s Foundation
Physicians for American Healthcare Access
Renal Physicians Association
Society for Cardiovascular Angiography and Interventions
Society for Cardiovascular Computed Tomography
Society of General Internal Medicine
Society of Hospital Medicine
Society of Teachers of Family Medicine
The National Association of Rural Health Clinics
The Society of Thoracic Surgeons

References
¹ Ahmed AA, Hwang WT, Thomas CR Jr, Deville C Jr. International Medical Graduates in the US Physician Workforce and Graduate Medical Education: Current and Historical Trends. J Grad Med Educ. 2018 Apr;10(2):214-218. doi: 10.4300/JGME-D-17-00580.1. PMID: 29686763; PMCID: PMC5901803.
² Liu M, Patel VR, Ramesh T, Vyas DA, Wadhera RK. Health Care Professionals Sponsored for H-1B Visas in the US. JAMA. 2025 Dec 9;334(22):2035-2038. doi: 10.1001/jama.2025.20931. PMID: 41160415; PMCID: PMC12573110.
³ Id.
⁴ Hailat R, Ridha M, Lin CC, Kerber K, Burke JF. Trends in the Proportion of US and International Medical Graduates at the County Level. JAMA. 2025 Oct 14;334(14):1294-1295. doi: 10.1001/jama.2025.12818. PMID: 40810946; PMCID: PMC12355384.
⁵ GlobalData Plc. The Complexities of Physician Supply and Demand: Projections From 2021 to 2036. Washington, DC: AAMC; 2024.