H-1B limits could hit primary care residencies hardest

Clinical takeaway: Some states carry both heavy reliance on internationally trained residents and severe physician shortages, so visa restrictions could surface as regional access gaps.

Match results get read as a forecast of physician supply over the coming years. For a meaningful share of trainees in first-contact specialties, though, completing residency and practicing in the US can run through two different visa pathways. And only one of them permits staying on.

Most international graduates train in the US on J-1 visas, which are built for clinical training and generally require returning home afterward. H-1B visas are employment based and allow practice in the US, making them the route by which a trainee becomes a local physician. That route is now in question, after an executive proclamation imposed a $100,000 H-1B fee, since blocked in court.

How many residents depend on each route is not directly measurable, because trainee-level visa data are not public. A new cross-sectional analysis estimated it using 2025 National Resident Matching Program counts for non-US international medical graduates entering first-year positions, matched against national J-1 sponsorship figures and federal shortage-area data. State-level figures mask program-level concentration, though, where dependence in any given residency may run much higher.

Non-US graduates filled 33.8% of first-year internal medicine positions, 19.7% in pediatrics, and 17.6% in family medicine. Across those three specialties that came to 4,964 residents, or roughly three quarters of all non-US graduates entering training that year. Their share was far lower in surgery, anesthesiology, and obstetrics-gynecology, each under 7%.

Reliance on international graduates was heaviest in the Northeast and Upper Midwest, where states exceeded 15 non-US graduates per 100 first-year positions, a level several Southern states also reached. Weighting each state's reliance by local shortage severity identified where the two overlap, concentrated in the Northeast and Midwest, marking the states least able to absorb a disruption. Most international graduates enter on J-1 visas, and by the authors' conservative estimate, 15% to 20% require H-1B sponsorship for the training position itself, or roughly 870 first-year primary care positions a year.

The issue is not confined to primary care. An accompanying commentary notes that in the 2026 fellowship match, more than a quarter of entering trainees in hematology, oncology, nephrology, rheumatology, and cardiology were noncitizen international graduates, specialties that carry much of the chronic disease burden in underserved areas.

Two things make this different from a gradual supply squeeze. Residency entry happens once a year, so a restriction landing between match cycles removes a whole cohort at once rather than thinning it slowly. And the pathway built to place physicians where they are needed runs through the same visa. Training-visa holders who stay to practice in a designated underserved area generally convert to an H-1B to do it. Narrowing that route narrows the mechanism meant to correct distribution.

"While a $100,000 H-1B visa fee may have been designed to address perceived abuses in high-wage markets, the policy functions as a tax on access to care in health care markets," wrote Atul Grover, MD, PhD, a visiting scholar at Stanford Medicine, and Joseph Antos, MA, PhD, a health economist at the American Enterprise Institute in the accompanying commentary.

They continue, "The US has never had a surplus of physicians wanting to train or practice in underserved communities, and the same fees designed for large corporations may force communities to choose between trying to keep labor and delivery services available in a rural hospital or hiring another primary care clinician."

Sources: Karamitros G, et al. JAMA Netw Open. 2026 Aug 17. H-1B visa restrictions and US primary care dependence on international medical graduates; Grover A, et al. JAMA Netw Open. 2026 Aug 17. Visa fee raises a new barrier to health care