SHELBY, N.C. — The overworked kidney doctors in this small town were supposed to get reinforcement this fall with the arrival of a new colleague from India. Patients already had appointments scheduled with the incoming nephrologist.
Then the Trump administration demanded that companies pay a $100,000 visa fee to bring highly skilled workers from abroad, including doctors and medical professionals urgently needed in health care deserts. Nephrology Associates of the Carolinas could no longer afford to sponsor the Indian kidney specialist, and it has not found an American well suited for the job.
Two months after President Donald Trump signed the executive order restricting H-1B visas, soaring costs are roiling rural health care facilities that have long struggled to find staff. The fee increase for visa applicants, coupled with broader crackdowns on legal pathways for foreign-born workers, threatens a growing industry and jeopardizes patients who need timely care, according to labor experts and immigration lawyers.
In Shelby, about an hour’s drive west of Charlotte, the three kidney doctors came from abroad, two working on H-1B visas. But retaining talent in a rural region can be hard: Another H-1B doctor decamped to Los Angeles last summer, increasing the others’ workload.
José Mena, who came to the practice from Ecuador on an H-1B visa, hopes to stay long-term in Shelby with his wife and young daughter. But Mena, 35, said he is taxed by frequent week-long on-call rotations, which involve phone consultations and hospital visits throughout the night, depriving him of family time.
“If someone else leaves from the practice, I’ll just leave too,” Mena said.
The new nephrologist, Vijaya Chelikani, 30, remains with her parents in Hyderabad, India, while the practice awaits a response to its request for the Trump administration to waive the fee under a vague “national interest” exemption.
“I’m stuck right now,” Chelikani said. “I want to start my job.”
In a statement, White House spokeswoman Taylor Rogers said the visa fee discourages companies “from spamming the system and driving down wages” and gives certainty to those who want to “bring high-skilled workers into our great country but have been trampled on by abuses of the system.”
Desperate rural need
The H-1B visa program allows U.S. employers to hire workers with specialized training from abroad for up to six years if they cannot find American workers to fill the jobs. Previously, the fees had typically ranged between $460 and $1,000 for nonprofit health care facilities. Companies often sponsor those workers for permanent residency. Some of Trump’s supporters have asserted that the program takes jobs from American workers, while left-leaning critics allege that companies exploit the workers for lower wages.
Nearly 400,000 new or renewed H-1B visas were granted last fiscal year, according to federal immigration data, mostly to Indian immigrants. About 17,000 of those work in the health sector.
These legal workers fill crucial gaps in rural and underserved regions, according to medical associations and health care researchers. Iowa, North Dakota and West Virginia — states that overwhelmingly voted for Trump in the last three elections — lead the nation with the highest percentage of physicians who hold H-1B visas, according to a study published this year.
Last year, the percentage of H-1B-sponsored doctors in rural counties was nearly twice the share in urban ones, according to research published in JAMA in October. Impoverished counties also had a significantly higher percentage of H-1B physicians, said lead author Michael Liu, a resident physician at Brigham and Women’s Hospital. Liu himself works on a trainee visa from Canada and hopes to eventually remain in the United States on an H-1B visa.
The most visible aspects of Trump’s sweeping immigration policies have targeted undocumented immigrants, but the policies are also reshaping legal immigration. The White House implemented a travel ban on people from certain countries and has increased scrutiny of visa applications. Last month, the State Department said visa applicants can be denied over obesity, diabetes or cancer.
The crackdown comes as rural hospitals are bracing for cuts to Medicaid, the health insurance program for the poor run by states and the federal government.
The administration’s policies will devastate hospitals already burdened by complex visa rules and costly legal fees, predicted Mira Mdivani, an immigration lawyer in Overland Park, Kansas, who represents Midwest medical providers. Qualified doctors, nurses and other medical professionals are in demand worldwide, and “the U.S. is becoming less and less attractive because we have these incredible hurdles,” she said.
As immigration rules tighten, the consequences are rippling through sectors already struggling with labor shortages, especially in rural areas.
Those include North Dakota, where communities have not attracted enough U.S.-born candidates, said Alfred Sams, president of the Rough Rider Network, an association of 22 independent rural hospitals in the state.
“My hospital is 10 miles away. The nearest stoplight is 80 miles away,” said Sams, who lives in Bottineau, near the Canadian border. “We also have winters that are 30 below zero.”
Rough Rider hospitals rely on foreign-born health care professionals and operate on slim or negative margins, Sams said, making the $100,000 fee for one worker insurmountable.
It’s not just doctors. For decades, the United States has lacked enough nurses. But visas typically used by foreign-born nurses have a years-long backlog — making H-1B visas a quicker option, said Karen Tumlin, an attorney with the Justice Action Center, a nonprofit representing companies suing to overturn the fee.
One health system in Louisiana involved in the lawsuit had more than 200 H-1B nurses lined up, which now would cost more than $20 million in fees, Tumlin said. “It’s just not doable,” she said.
The American Hospital Association and dozens of medical associations have lobbied the Trump administration to exempt health workers from the fee. Neither the Department of Homeland Security, which can grant exemptions, nor the White House answered questions about the trade groups’ request.
Simon Hankinson, a senior immigration research fellow at the conservative Heritage Foundation and an H-1B critic, called the fee a “step in the right direction” toward reforming a program that he described as a crutch for industries to hire cheap labor. Long term, he said, the measure will push U.S. students toward the medical field and incentivize schools to expand programs.
“The American labor market has to be able to adjust,” Hankinson said.
Colleen F. Molner, who leads the health care practice at Garfinkel Immigration Law Firm in Charlotte and represents Nephrology Associates of the Carolinas, said Trump’s proclamation and the guidance that U.S. Citizenship and Immigration Services (USCIS) issued for it are vague on exemptions. She is arguing that several of her clients qualify for exemptions based on the shortages of health care professionals in their communities, while other companies are pausing their sponsorships.
“It’s definitely having a chilling effect,” Molner said.
Uncertainty in North Carolina
In North Carolina, health systems say they are in dire need of medical technicians, who analyze blood, urine and other bodily fluids for abnormalities.
Iredell Health System — serving Iredell County’s mix of rural communities, suburban neighborhoods of Charlotte commuters and upscale lakefront homes — is asking USCIS to waive fees for a medical technician from the Philippines. The woman would join a fellow Filipina technician, April Joy Castañeto, 30, who arrived at the hospital in Statesville on a H-1B visa last year.
Castañeto had a good job in her rural Philippine province but wanted a better life, and now works the overnight shift processing samples and analyzing results in a humming, sophisticated lab that patients never see.
As with many current H-1B holders, the president’s September proclamation struck fear in Castañeto. She has delayed returning to the Philippines to visit family out of concern that immigration officials won’t let her back in.
Meanwhile, Chelikani, the kidney doctor hired to work in Shelby, remains stuck.
After graduating from medical school in India, she arrived in the United States in 2020 on a trainee visa for a residency in Michigan and a two-year nephrology fellowship in Alabama. To stay in the country longer, Chelikani agreed to work for three years in what the federal government has deemed a “health professional shortage area.”
The federal government preliminarily authorized her to stay after the Shelby practice submitted documentation to show that it had contracted a recruiting service and advertised in numerous medical journals and websites but got only two U.S. applicants. One wanted to work doing transplants, which local hospitals do not offer, and another had cycled through numerous jobs, said Michaelle Waters, the practice’s office manager.
Chelikani returned to India to visit family, believing she would stay for only a few months while the H-1B paperwork was finalized. Her shoes, clothes and furniture are still in storage in Charlotte.
In Shelby, the uncertainty has cast a pall over the office — the only kidney specialists serving a region of more than 165,000 residents. The practice nearly shut down several years ago when it had only one doctor left: the owner, Muhammad Alam. Born in Bangladesh, he arrived on a trainee visa in the mid-1990s and moved to Shelby more than a decade later. He and his wife raised three daughters here, including one who’s now a doctor in residency and another in medical school.
While H-1B doctors have kept the practice operating, new patients face long waits because those with severe kidney disease take priority. Many dialysis patients, often elderly, cannot easily travel to the nearest big city, Charlotte, for hours-long treatments three times a week. As the population around Shelby grows, doctors are seeing more patients — and many younger ones with health problems that contribute to kidney disease, Alam said.
His office is considering obtaining a loan to cover the visa and operating expenses. “If we don’t have this practice, patients will suffer,” Alam said.
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