Medicine Calls for Exemption to New $100,000 H-1B Visa Application Fee
By Phil West

International medical graduates (IMGs) make up about a quarter of Texas’ physician workforce, considering both licensed physicians and residents. But a White House executive order, requiring a new $100,000 fee for H-1B work visa applicants, could squeeze this crucial pipeline in meeting health care needs.

The move also could threaten a new Texas law allowing IMGs to secure two new types of licenses to practice in the state, adding a high financial hurdle to IMGs who are not U.S. citizens. The H-1B nonimmigrant visa program enables U.S. employers to hire foreign-born professionals for specialty occupations, including health care, typically requiring at least a bachelor’s degree.

The American Medical Association, joined by a coalition of national medical groups, is requesting physicians be exempt from the new H-1B visa application fee requirement, which was issued via the Sept. 19 executive order and applies to all petitions from Sept. 21 on. As of this writing, an Oct. 3 lawsuit challenging the executive order was pending in the U.S. District Court of the Northern District of California.

AMA’s letter to Secretary of the Department of Homeland Security Kristi Noem noted a clause in the executive order allowing fee waivers for certain workers or occupations if it “is in the national interest and does not pose a threat to the security or welfare of the United States.”

“As you establish standards to define categories of H-1B workers covered by this exception, we urge you to clarify that all physicians, including medical residents, fellows, researchers, and those working in nonclinical settings, are critical to our national interest,” the Sept. 25 letter said.

“The U.S. health care workforce relies upon physicians from other countries to provide high-quality and accessible patient care,” the letter points out, calling for the fee waiver “so that H-1B physicians can continue to be a pipeline that provides health care to U.S. patients.”

IMGs comprise 23% of licensed physicians in the U.S. per 2024 data from the Federation of State Medical Boards. In Texas, IMGs represent about 26% of the 75,000-plus physicians in Texas, per Texas Medical Board data from January, and 22% of Texas medical residents are IMGs, according to the Association of American Medical Colleges.

“It’s a major concern for all of us,” said Rajeev Suri, MD, professor and chair of the department of radiology at  UT Health San Antonio Long School of Medicine and chair of the Texas Medical Association’s International Medical Graduate Section, adding the section has been in communication with its AMA counterpart upon learning of the new fee.

The IMG pipeline is important for addressing future projected physician workforce shortages as well as present needs, and some residents, for instance, provide health care to Texans in designated health professional shortage areas, he says.

IMGs who hope to enter residency training in Texas next July and the residency programs reviewing their applications now have to weigh the hefty fee in their decision-making. Dr. Suri is concerned financial obstacles placed before applicants now could start adversely impacting Texas residency programs nine months from now.

Hospitals statewide are particularly reliant on residents, TMA staff also notes, as they work up to 80 hours a week and can work even more under certain exceptions. Replacing residents with advanced practice registered nurse or physician assistants would cost hospitals more, according to TMA research, likely requiring two nonphysician practitioners to fill in for one resident, potentially creating staffing shortages, heavier caseloads for teaching faculty, greater costs, and subsequent access-to-care concerns.

In addition, Texas legislators passed House Bill 2038 in the 2025 session, authored by Rep. Tom Oliverson, MD (R-Cypress), with Rep. Suleman Lalani, MD (D-Sugar Land), and others, geared toward bringing more IMGs and unmatched medical graduates into the state’s physician workforce.

The new law, known as the “Doctor Act,” establishes two new state medical licenses available to IMGs. The first is a provisional license for IMGs that meet specific requirements, including:

• Have a doctor of medicine or similar degree from a medical education program and be licensed to practice in another country that both meet certain eligibility stipulations;
• Have completed residency training or similar postgraduate medical training required by the country of licensure;
• Have passed the first and second steps of the U.S. Medical Licensing Exam within three attempts for each step, as defined in state law;
• Pass the Texas Medical Jurisprudence Exam; and
• Have been offered employment as a physician in Texas by a person who provides health care services in a facility-based or group practice setting that meets certain conditions.

The law also establishes a limited license for physician graduates. This license will be offered for physicians who graduated from medical school in the U.S. or another country but are not enrolled in residency training in the U.S. A different set of eligibility criteria applies, and licensees are required to practice under physician supervision and in Texas counties with less than 100,000 people. 

Both the provisional and limited license would require IMGs be authorized under federal law to work in the U.S. and have proficiency in the English language.

TMA staff expressed concern that even if physicians are exempted from the new H-1B application fee, the new policy could have a “chilling effect” on physician applications, even as HB 2038 is encouraging them to explore the possibility of practicing in state.

TMA staff is also monitoring HB 2038’s implementation, with rulemaking by the Texas Medical Board due Jan. 1.