The health care system in this country is dealing with a lot right now. Affordable Care Act subsidies are expiring. New Medicaid restrictions are looming. And finding enough health care workers to meet demand  is difficult at the best of times. 

On top of all that, the $100,000 fee imposed by President Donald Trump on new H-1B visa applications has added extra pressure to health care systems in rural and low-income communities in the U.S. 

While talk of H-1B visas usually revolves around the tech industry — Big Tech uses the program the most by far — the visa has become a critical pipeline for highly-trained health workers to fill critical roles outside of wealthy urban centers. 

“There is a persistent and ongoing workforce shortage” at rural hospitals and clinics, said Janessa Graves, director of the University of Washington’s Rural Health Research Center. 

Providers in hard-to-reach and sparsely-populated areas, which cannot afford to pay the H-1B fee and could see their workforces shrink as a result, are worried that patient access to healthcare could suffer. 

“That results in long waiting times for local care, or lots of driving, and a huge burden for patients who may not have transportation or the funds to get from point A to point B, to the city to see a specialist,” Graves said. 

Frederick Health Hospital in rural Frederick County, Maryland, is ground zero for the hurdles the new fee has created. The hospital is the only emergency room in a county that’s approximately 650 square miles in size. Patients would have to drive as far as 50 miles to get to another facility. 

“We see about 70,000 to 80,000 emergency department visits — one of the busiest emergency departments in the state,” said Jamie White, chief nursing officer at Frederick Health. 

Not only is her hospital one of the busiest in the state, it’s also chronically short-staffed. White said it can’t compete with salaries at hospitals in urban areas or with jobs that allow for more work-life-balance. 

“If I have a choice of working all night long on my feet for 12 hours … or I'm able to work in a clinic Monday through Friday, there’s a lot of nurses that are choosing to do other things than working in a hospital,” she says. 

This year, Frederick Health finally decided to recruit from overseas. But, just as foreign applicants accepted job offers, Trump imposed the new fee on H-1B visas. 

“The expectation before the September change was to pay a fee of around $200 per nurse for the H-1B visas. But the $100,000 we can't afford paying that for one nurse, so we will not be able to do this if that’s the case,” White said. 

The 29 nurses Frederick Health was expecting right around this time of year are not coming. For now, White is relying on stopgap measures like more overtime. 

There’s some hope that health care providers can apply for exemptions from the fee, and Frederick Health has done so. But, it’s unclear how long that process could take or if the Trump administration will grant those exemptions. 

“The fee is a non-starter,” said Ann-Rose Johnson-Lewis, director of legal services at WorldWide HealthStaff Solutions, which typically brings in 200 to 300 nurses a year through H-1B visas to work at health systems in rural and low-income Midwestern communities.

“They just simply cannot afford it. This is not sustainable. So at the moment, H-1B for health care workers is at a standstill,” Johnson-Lewis said. 

There is another visa called EB-3, which is also used to bring in nurses, but processing times for that visa can take several years. The H-1B is faster. 

The new fee is not just limiting nurses. It’s affecting doctors, surgeons, and a whole host of other health care workers. An article in the Journal of the American Medical Association detailed those professionals: physician assistants, nurse practitioners, nurse anesthetists, podiatrists, chiropractors, optometrists, and others. 

Dr. Michael Liu, a clinical fellow in medicine at Brigham and Women’s Hospital, co-authored the report, which relied on government data on visa applications and the official count of healthcare jobs in the country. 

Liu’s research shows that while health care workers make up a small percentage of each year’s H-1B visa applications, workers who come into the U.S. healthcare system through that pathway play a critical role in shoring up the system. 

“The big takeaway there is that the most rural and impoverished communities depend much more heavily on H-1B sponsored physicians and health care workers than other communities,” Liu said. 

For example, he found that health systems in rural areas brought in twice as many H-1B workers as urban ones. Parts of the country utilizing the visa most heavily to bring in doctors, according to Liu, include Ripley County, Missouri; Galax, Virginia; and Cavalier, North Dakota — with populations ranging between 1,220 and 10,715. 

Overall, about 64% of foreign-trained physicians were practicing in areas deemed as “medically underserved” or experiencing health worker shortages, according to the American Medical Association. 

Business, health care and academic groups have filed a couple of lawsuits challenging the new H-1B fee. The cases are in their early stages and could take months longer to play out. 

“A lot of employers are kind of just waiting to see what would happen with those lawsuits,” Johnson-Lewis said.