As the nation’s physician shortage worsens, some fear the Trump administration’s immigration policies will dissuade or prevent doctors who earned their medical degrees in foreign countries from practicing in the United States.

Among all U.S. doctors, an estimated one quarter were educated abroad. But they make up an even larger proportion of physicians in many specialties, including internal medicine (41%), endocrinology (46%) and geriatrics (52%).

The U.S. has long welcomed foreign-educated physicians as a way to ameliorate its doctor shortage. Already, an estimated 102 million Americans live in communities that don’t have enough primary care providers, according to the federal Health Resources and Services Administration. The agency projects a shortage of 141,160 full-time physicians by 2038.

Foreign-educated doctors are slightly more likely than American ones to work in areas with a shortage of primary care providers. And doctors who are here on H-1B visas — a federal program that allows U.S. employers to temporarily hire non-citizen workers for health care jobs and other positions requiring specialized knowledge — are more likely to work in high-poverty areas.

But last August, the Trump administration issued a rule increasing the fee for employers hiring workers through the H-1B visa program to $100,000, up from between $2,000 and $5,000. It also has issued a travel ban on residents of 39 countries. And earlier this month, the U.S. State Department broadened its “online presence review” of applicants for H-1B and other visas to ensure that they do not “pose a threat to national security or public safety.”

“The United States remains vigilant throughout the visa issuance process to confirm that applicants do not intend to cause harm to Americans or threaten U.S. interests,” the State Department said in its announcement of the expanded vetting.

Dr. Tarun Ramesh, a physician at Massachusetts General Hospital and a health policy researcher at Harvard Medical School, said Trump’s policies will make it more expensive for hospitals and other healthcare employers to hire foreign physicians and might dissuade many international doctors from coming here at all.

“We’ve created a system where we depend heavily on physicians trained abroad, and at the same time, we create immigration policies that make it harder for those physicians to enter, to train, to remain in the country,” Ramesh said. “And that intersection of both the health workforce and immigration workforce and immigration policy makes it a clear tension.”

Both left-leaning and conservative states have taken steps to attract foreign physicians.

As of the middle of this year, about two-dozen states of every political bent had enacted laws to make it easier for foreign nationals to get their U.S. medical licenses.

Georgia Republican state Sen. Dr. Ben Watson, who co-sponsored a law in his state, said there simply aren’t enough U.S. medical school graduates to keep pace with population growth. He said one of his main goals is to increase the number of doctors in rural areas.

“We did it in several different stages to assure quality,” Watson said. “Hopefully we can encourage rural migration from that standpoint, also.”

Since 1994, states also have used the federal Conrad 30 Waiver Program to boost the number of doctors in underserved areas. The law allows a limited number of foreign medical school graduates who have trained in the U.S. using a J-1 visa to waive the normal requirement that they return to their home countries for two years before applying to come back — as long as they practice in an underserved area.

In increasing the H-1B visa fee, the Trump administration argued that some employers, especially tech companies, have abused the program by using it to replace native-born workers with foreigners who will work for less, rather than using it to fill jobs they can’t find Americans to do.

“American IT workers have reported they were forced to train the foreign workers who were taking their jobs and to sign nondisclosure agreements about this indignity as a condition of receiving any form of severance,” President Donald Trump said in the executive order he issued in September 2025. “This suggests H-1B visas are not being used to fill occupational shortages or obtain highly skilled workers who are unavailable in the United States.”

But 20 Democratic-led states sued to stop the fee increase, and in June a federal judge ruled in their favor. The administration was thwarted again in September, but it isn’t giving up: its latest proposal is to levy a $103,265 fee for a subset of H-1B applicants.

Even as the legal wrangling continues, the administration’s proposal has had an effect. In November survey of its members, the American Hospital Association found that 64% of hospitals that utilize the H-1B program had paused, deferred or limited recruitment because of the possibility of the $100,000 fee.

Andrew Wizner, an attorney who represents medical institutions that hire foreign medical school graduates, said the onslaught of new rules, legislative holdups, and confusing court decisions almost certainly has dissuaded some H-1B and J-1 visa applicants from applying to practice or train here.

“If you’re outside the U.S. and loosely following, (you might think) ‘Oh, there’s this rule, and I heard a court may have set it aside, but I don’t really know how their system works, their judicial system, and what that means,’” Wizner said.

He said the message that foreign-educated doctors are receiving is a simple one: “Don’t come here.”

Bradley Cunningham, a regulatory affairs and policy analyst at the Association of American Medical Colleges, said most hospitals simply can’t afford to navigate the new legal challenges and fees associated with H-1B visas.

“There’s a tremendous amount of confusion and misinformation about what’s going on,” Cunningham said. Like Wizner, he said he suspects the uncertainty swirling around H-1B visas is causing many would-be applicants to think twice about coming to the U.S.

“We can’t determine causality, but I can’t imagine that that is helping the situation any more when you’re talking about having to commit your family to come overseas to train at an institution and not having security or assurance that you can complete your training.”

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

WASHINGTON — A federal appeals court Friday struck down the Trump administration’s policy to quickly send noncitizens to countries they are not from, finding that immigrants must have an opportunity to challenge their removal if they fear for their safety.

The decision largely upheld a Boston federal judge’s February ruling that found the Department of Homeland Security’s policy unlawful. But the immigration officers can still conduct third-country removals if they follow the proper procedures, such as adequate notice and an opportunity for an immigrant to raise a fear-based claim to that country of removal.

Third-country removals, deportations from the United States to a nation other than an immigrant’s home country, occur when the immigrant’s home country does not accept the person’s repatriation. 

Once rare, the procedure has spiked under the second Trump administration that has entered into partnerships with several countries, some with human rights concerns, to take third-country removals from the U.S.

The three-judge panel of the U.S. Court of Appeals for the 1st Circuit also raised doubts that a country that accepts a person that is not their own citizen could “credibly provide blanket assurances that all removed noncitizens will not be persecuted or tortured there unless it intends to provide them with some sort of affirmative protection against rogue agents and non-state actors.” 

The panel also upheld the lower court’s finding that the notice to a third country was inadequate – about 24 hours – and that the policy was unlawful.

It gives “no notice at all of an impending third-country removal when the country to which the noncitizen is to be removed has provided credible (in the State Department’s judgment) diplomatic assurances that noncitizens removed there from the United States will not be persecuted or tortured,” the panel wrote.

The panel included circuit judges Lara E. Montecalvo, Jeffrey R. Howard and Seth R. Aframe. Former President Joe Biden nominated Montecalvo and Aframe. Former President George W. Bush nominated Howard.

The Trump administration in May 2025 made an emergency request to the Supreme Court after U.S. District Judge Brian Murphy blocked the policy. The Supreme Court in June 2025 temporarily allowed for the removals, before sending it back to the lower court. 

Murphy again in February issued an order that blocked the policy and required DHS to carry out the statutory obligations of proper notice of removal to a third country and to give a noncitizen enough time to raise any concerns for their safety to their removal to a third country. 

The Trump administration later appealed to the First Circuit, and could appeal again to the Supreme Court. 

DHS did not respond to States Newsroom’s request for comment Friday. 

WASHINGTON — The Trump administration wants to overhaul the U.S. census to exclude noncitizens who don’t have a green card from the country’s next population count in 2030, according to a Wednesday notice in the Federal Register. 

The document, which will officially be published Thursday, could mean major changes for how millions in federal funding is allocated to states, as well as affect the population numbers for determining the number of U.S. House members in each state. The House is made up of 435 lawmakers apportioned among congressional districts in the 50 states.

The move is likely to face legal challenges, as the changes run counter to the U.S. Constitution’s 14th Amendment that directs representatives in Congress to be appointed based on the “whole number of persons in each State,” excluding Native Americans “not taxed.” 

The amendment language does not specify immigration status. The states handled immigration enforcement until the federal government took over in 1882 with the passage of the Chinese Exclusion Act. 

The proposed changes would exclude any noncitizens who do not have lawful permanent residence, or a green card, which could result in millions being excluded from the population count. That would include immigrants in the country without legal authorization, those with some form of temporary legal status, refugees and asylum seekers. 

The unauthorized immigrant population — that includes noncitizens who have some form of limited legal status — has grown to more than 15.8 million since mid-2024.

The Trump administration argues that noncitizens who are not green card holders should be kept out of the census count because “they are not true inhabitants, members of the body politic, or persons with a ‘usual residence’ in the United States due to their lack of a sufficient tie and allegiance to the United States,” according to the document. 

The proposal also calls for removing several questions pertaining to sexual orientation, race and ethnicity, and suggests adding a question relating to citizenship, which President Donald Trump has pushed to include since his first term. But the Supreme Court in 2019 kept the question off the 2020 census. 

The Trump administration wants those demographic questions removed from the census because the survey “should be colorblind and should not be distorted in any way by questions about immaterial personal characteristics, such as race,” the proposal says.

The census has collected information about race and ethnicity since 1790, the first survey count in the U.S.

Public comment will last for 30 days after the document is officially published Thursday.

WASHINGTON —  Temporary protected status for 170,000 Salvadorans is set to expire at midnight Wednesday, but the Department of Homeland Security said protections will remain in place until the Trump administration makes a decision to extend or terminate El Salvador’s designation, in place since 2001.

“An announcement on El Salvador’s TPS will be made at the appropriate time,” a DHS spokesperson said in an email to States Newsroom. “Until such announcement is made, Salvadoran individuals present in the U.S. under TPS retain protection.”

Based on the temporary protected status statute, if a determination to extend or terminate a country’s protections is not made by the government by the expiration of the deadline, then TPS is automatically extended for six months.

If the Trump administration does make a determination to end protections, then Salvadorans will have 60 days to leave the United States.

Homeland Security Secretary Markwayne Mullin has not indicated his plans for El Salvador’s temporary legal protections. Additionally, there is no notice in Wednesday’s Federal Register or a preview of Thursday’s edition regarding TPS for El Salvador. 

On Tuesday, White House border czar Tom Homan said the decision would be up to Mullin, but added that El Salvador is now much safer than when its previous designation was made in 2001. 

If TPS is terminated for nationals for El Salvador, they will be the latest large group of immigrants to lose their legal status in the country as President Donald Trump has sought to dismantle the program Congress created for people who hail from countries deemed too dangerous for return. 

The Supreme Court has accelerated that move. The court’s conservative majority this summer determined that the TPS statute does not allow decisions on country designations, terminations and extensions to be subject to judicial review. 

Before the start of the second Trump administration, 17 countries had TPS, totaling to about 1.3 million immigrants with legal status. 

Now, if TPS for El Salvador ends, only three countries will remain: Lebanon, Sudan and Ukraine. 

TPS is granted to nationals who hail from a country experiencing a natural disaster, violence, or other extreme circumstances, allowing them to remain in the U.S. and obtain work permits that last for six-to-18-month cycles. 

Each renewal process requires a TPS holder to go through a background check and pay hundreds of dollars in fees as well as undergo other vetting.  

If TPS ends for El Salvador, it could stymie the country’s economy, where more than a quarter of its gross domestic product relies on money sent back to the country from Salvadorans in the U.S., known as remittances. 

El Salvador’s president, Nayib Bukele, also has a close relationship with the Trump administration, ranging from accepting deportees that are not Salvadoran into his country to visiting the president at the White House.

In 2019, Bukele asked the first Trump administration to extend TPS protections, not because El Salvador was unsafe, but because the end of designation would break apart families in the U.S. 

Bukele has not made any recent public calls for the Trump administration to continue TPS for Salvadorans.