Bekki Holzkamm has been trying to hire a lab technician at a hospital in rural North Dakota since late summer.

Not one U.S. citizen has applied.

West River Health Services in Hettinger, a town of about 1,000 residents in the southwestern part of the state, has four options, and none is good.

The hospital could fork over $100,000 for the Trump administration’s new H-1B visa fee and hire one of the more than 30 applicants from the Philippines or Nigeria. The fee is the equivalent of what some rural hospitals would pay two lab techs in a year, said Holzkamm, who is West River’s lab manager.

West River could ask the Department of Homeland Security to waive the fee. But it’s unclear how long the waiver process would take and if the government would grant one. The hospital could continue trying to recruit someone inside the U.S. for the job. Or, Holzkamm said, it could leave the position unfilled, adding to the workload of the current “skeleton crew.”

The U.S. health care system depends on foreign-born professionals to fill its ranks of doctors, nurses, technicians, and other health providers, particularly in chronically understaffed facilities in rural America.

But a new presidential proclamation aimed at the tech industry’s use of H-1B visas is making it harder for West River and other rural providers to hire those staffers.

“The health care industry wasn’t even considered. They’re going to be collateral damage, and to such an extreme degree that it was clearly not thought about at all,” said Eram Alam, a Harvard associate professor whose new book examines the history of foreign doctors in the U.S.

Elissa Taub, a Memphis, Tennessee-based attorney who assists hospitals with the H-1B application process, has been hearing concerns from her clients.

“It’s not like there’s a surplus of American physicians or nurses waiting in the wings to fill in those positions,” she said.

Until recently, West River and other employers paid up to $5,000 each time they applied to sponsor an H-1B worker. The visas are reserved for highly skilled foreign workers.

The new $100,000 fee — part of a September proclamation by President Donald Trump — applies to workers living outside the U.S. but not those who were already in the U.S. on a visa.

West River lab tech Kathrine Abelita is one of nine employees — six technicians and three nurses — at the hospital who are current or former H-1B visa holders. Abelita is from the Philippines and has worked at West River since 2018. She’s now a permanent U.S. resident.

“It’s going to be a big problem for rural health care,” she said of the new fee. She said most younger American workers want to live in urban areas.

Sixteen percent of registered nurses, 14% of physician assistants, and 14% of nurse practitioners and midwives who work in U.S. hospitals are immigrants, according to a 2023 government survey. Nearly a quarter of physicians in the U.S. went to medical school outside the U.S. or Canada, according to 2024 licensing data.

The American Hospital Association, two national rural health organizations, and more than 50 medical societies have asked the administration to give the health care industry exemptions from the new fee. The new cost will disproportionally harm rural communities that already struggle to afford and recruit enough providers, the groups argue.

“A blanket exception for healthcare providers is the simplest path forward,” the National Rural Health Association and National Association of Rural Health Clinics wrote in a joint letter.

The proclamation allows fee exemptions for individuals, workers at specific companies, and those in entire industries when “in the national interest.” New guidance says the fee will be waived only in an “extraordinarily rare circumstance.” That includes showing that there is “no American worker” available for the position and that requiring a company to spend $100,000 would “significantly undermine” U.S. interests.

Taub called those standards “exceptionally high.”

Representatives of the NRHA and the American Medical Association, which organized a letter from the medical societies, said they’ve received no response after sending requests to Homeland Security Secretary Kristi Noem in late September and early October. The AHA declined to say whether it had heard back.

Homeland Security officials directed KFF Health News’ inquiries to the White House, which did not answer questions about individual waiver timelines or the possibility of a categorical exemption for the health care industry.

Instead, White House spokesperson Taylor Rogers sent a statement defending the new fee, saying it will “put American workers first.” Her comments echo Trump’s proclamation, which focuses on accusations that the tech industry is abusing the H-1B program by replacing American workers with lower-paid foreign ones. But the order applies to all trades.

Alam, the Harvard professor, said the U.S.’ reliance on international providers does raise legitimate concerns, such as about how it takes professionals away from lower-income countries facing even greater health concerns and staffing shortages than the U.S.

This decades-long dependency, she said, stems from population booms, medical schools’ historical exclusion of nonwhite men, and the “much, much cheaper” cost of importing providers trained abroad than expanding health education in the U.S.

Internationally trained doctors tend to work in rural and urban areas that are poor and underserved, according to a survey and research review.

Nearly 1,000 H-1B providers were employed in rural areas this year, the two rural health organizations wrote in their letter to the Trump administration.

J-1 visas, the most common type held by foreign doctors during their residencies and other postgraduate training in the U.S., require them to return to their home country for two years before applying for an H-1B.

But a government program called the Conrad 30 Waiver Program allows up to 1,500 J-1 holders a year to remain in the U.S. and apply for an H-1B in exchange for working for three years in a provider shortage area, which includes many rural communities.

Trump’s proclamation says employers that sponsor H-1B workers already inside the U.S., such as doctors with these waivers, won’t have to pay the six-figure fee, a nuance clarified in guidance released about a month later.

But employers will have to pay the new fee when hiring doctors and others who apply while living outside the U.S.

Alyson Kornele, CEO of West River Health Services, said most of the foreign nurses and lab techs it hires are outside the U.S. when they apply.

Ivan Mitchell, CEO of Great Plains Health in North Platte, Nebraska, said most of his hospital’s H-1B physicians were inside the U.S. on other visas when they applied. But he said physical therapists, nurses, and lab techs typically apply from abroad.

Holzkamm said it took five to eight months to hire H-1B applicants at her lab before the new fee was introduced.

Bobby Mukkamala, a surgeon and the president of the American Medical Association, said Republican and Democratic lawmakers are concerned about the ramifications for rural health care.

They include Senate Majority Leader John Thune, who said he planned to reach out about possible exemptions.

“We want to make it easier, not harder, and less expensive, not more expensive, for people who need the workforce,” the Republican told KFF Health News in September.

Thune’s office did not respond to questions about whether the senator has heard from the administration regarding potential waivers for health workers.

The Trump administration is facing at least two lawsuits attempting to block the new fee. One group of plaintiffs includes a company that recruits foreign nurses and a union that represents medical graduates. Another lawsuit, by the U.S. Chamber of Commerce, mentions concerns about the physician shortage and health systems’ ability to afford the new fee.

Kornele said West River won’t be able to afford a $100,000 fee so it’s doubling down on local recruiting and retention.

But Holzkamm said she hasn’t been successful in finding lab techs from North Dakota colleges, even those who intern at the hospital. She said West River can’t compete with the salaries offered in bigger cities.

“It’s a bad cycle right now. We’re in a lot of trouble,” she said.

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

David Garza sometimes feels as if he doesn’t have health insurance now that he pays so much to treat his Type 2 diabetes.

His monthly premium payment of $435 for family coverage is roughly the same as the insurance at his previous job. But the policy at his current job carries an annual deductible of $4,000, which he must pay out-of-pocket for his family’s care until he reaches that amount each year.

“Now everything is full price,” said the 53-year-old, who works at a warehouse just south of Dallas-Fort Worth. “That’s been a little bit of a struggle.”

To reduce his costs, Garza switched to a lower-cost diabetes medication, and he no longer wears a continuous glucose monitor to check his blood sugar. Since he started his job nearly two years ago, he said, his blood sugar levels have inched upward from an A1c of 7% or less, the target goal, to as high as 14% at his most recent doctor visit in November.

“My A1c is through the roof because I’m not on, technically, the right medication like before,” Garza said. “I’m having to take something that I can afford.”

Plans with high deductibles — the amount that patients must pay for most medical care before insurance starts pitching in — have become increasingly common. In 2024, half of private-industry employees participating in medical care plans were offered this type of insurance, up from 38% in 2015, according to federal data. Such plans are also offered through the Affordable Care Act marketplace.

With ACA marketplace premiums for next year increasing and many of the subsidies to help people pay for them poised to expire at year’s end, more people face tough choices as they weigh monthly premium costs against deductibles. To afford insurance at all, people may opt for a plan with low premium payments but with a high deductible, gambling that they won’t have any medical crises.

But high-deductible plans pose a particular challenge for those with chronic conditions, such as the 38 million Americans who live with Type 1 or Type 2 diabetes. Adults with diabetes who are involuntarily switched to a high-deductible plan, compared with adults on other types of insurance, face an 11% higher risk of being hospitalized with a heart attack, a 15% higher risk of hospitalization for a stroke, and more than double the likelihood that they’ll go blind or develop end-stage kidney disease, according to a study published in 2024.

“All of these complications are preventable,” said Rozalina McCoy, the study’s lead author.

Care vs. Cost

The initial rationale behind such high-deductible plans was to encourage people to become wiser health care shoppers, said McCoy, an associate professor of medicine at the University of Maryland School of Medicine in Baltimore. And they can be a good fit, proponents say, for people who don’t use a lot of medical care or who have cash on hand for a health crisis.

But while people with an excruciating earache will seek care, McCoy said, those with unhealthy blood sugar levels might not feel as urgent a need to seek treatment — despite the potential long-term damage — given the acute financial pain.

“You have no symptoms until it’s too late,” she said. “At that point, the damage is irreversible.”

Overall, medical care for people with diabetes costs insurers and patients an average of $12,022 annually to treat the disease, according to an analysis of 2022 data. Type 2 diabetes, the more common form, is diagnosed when the body can no longer process or produce enough insulin to adequately regulate blood sugars. With Type 1, the body can’t produce insulin. Those with the disease may end up on the financial hook not just for insulin and other types of medication but for related equipment.

Mallory Rogers, whose 6-year-old daughter, Adeline, has Type 1, calculates that it costs roughly $1,200 a month for insulin, a pump, and a continuous glucose monitor. That figure doesn’t include the cost of emergency supplies needed in case Adeline’s technology malfunctions. Those include another type of insulin, blood-testing strips, and a nasal spray that’s nearly $600 for a two-pack of vials — supplies that must be replaced once a year or more frequently.

“If she doesn’t have insulin, it would become an emergency situation within two hours,” said Rogers, a technology consultant who lives in Sanford, Florida. Rogers has been saving for the coming year when her daughter moves to the high-deductible health plan offered by Rogers’ employer, which has a $3,300 deductible for family coverage.

Taxing Decisions

Many insurance plans carry increasingly high deductibles. But to be defined as a high-deductible health plan — and thus be eligible to offer a health savings account — a plan’s deductible for 2026 must be at least $1,700 for an individual and $3,400 for a family, according to IRS rules.

Health savings accounts enable people to squirrel away money that can be rolled over from year to year to be used for eligible medical expenses, including prior to meeting a deductible. Such accounts, available through a plan or employer, can provide tax benefits. The contributions are limited to $4,400 individually and $8,750 for a family in 2026, and employers may contribute toward that total. Rogers’ employer pays $2,000 spread out over the year, and Garza’s contributes $1,200.

Rogers recognizes that she’s fortunate to have accumulated $7,000 so far in her health savings account to prepare for her daughter’s insurance shifting to Rogers’ plan.

“Adding a financial burden to an already very stressful medical condition, it hurts my heart,” she said, reflecting on those who can’t similarly stockpile. “Nobody asks to have diabetes, Type 1 or Type 2.”

The median deductible for employer health insurance plans was $2,750 in 2024, but deductibles can run $5,000 or higher, said George Huntley, CEO of both the Diabetes Leadership Council and Diabetes Patient Advocacy Coalition.

When deductibles are too high, Huntley said, routine maintenance is what patients skimp on: “You don’t take the drug that you’re supposed to take to maintain your blood glucose. You ration your insulin, if that’s your scenario. You take pills every other day.”

Garza knows he should do more to control his blood sugar, but financial realities complicate the equation. His previous health plan covered a newer class of diabetes medication, called a GLP-1 agonist, for $25 a month. He wasn’t charged for his remaining medications, which included blood pressure and cholesterol drugs, or his continuous glucose monitor.

With his new insurance, he pays $125 monthly for insulin and several other medications. He doesn’t see his endocrinologist for checkups more than twice a year.

“He wants to see me every three months,” Garza said. “But I told him it’s not possible at $150 a pop.”

Plus, he typically needs lab testing before each visit, an additional $111.

In 2026, the deductible for a “silver”-level plan on the marketplace will average $5,304 without cost-sharing reductions, according to an analysis from KFF, a health think tank that includes KFF Health News. For a “bronze”-level plan, it will be $7,476. An annual visit and some preventive screenings, such as a mammogram, would be covered free of cost to the patient.

Moreover, people comparing plan options, whether through their employer or the marketplace, should figure out their annual out-of-pocket maximum, which still applies after the deductible is met, Huntley said.

Garza’s family policy requires him to pay 20% until he reaches $10,000, for example.

Given Garza’s high blood sugar levels, his doctor prescribed a fast-acting form of insulin to take as needed with meals, which costs an additional $79 monthly. He planned to fill it in December, when he’s responsible for only 20% of the cost after he has hit his deductible but not yet reached his out-of-pocket maximum.

Garza likes his job despite its health plan, saying he’s never missed a day of work, even recently when he had a stomach bug. As of late 2025, he remained conflicted about whether to sign up for health insurance when his company’s enrollment period rolls around in mid-2026.

He worries that dropping insurance would place his family too much at risk if a major medical crisis struck. Still, he pointed out, he could then use the money he now spends on monthly premiums to directly pay for care to better manage his diabetes.

“I’m just stuck, to be honest with you,” he said.