Visa-dependent graduates matched at a five-year low in 2026 as courts, the White House, and DHS pulled H-1B costs in different directions. Conrad 30’s status adds doubt.
Key Takeaways
- IMGs anchor the workforce: International medical graduates made up 29 percent of active U.S. psychiatrists in 2020 AMA data, against 23 percent across all other specialties.
- The visa pipeline is narrowing: Psychiatry filled 97.4 percent of 2,516 residency positions in 2026, while foreign-born graduates needing visa sponsorship matched at 54.4 percent, a five-year low.
- No H-1B fee is being collected: Two federal courts have vacated the policies behind the $100,000 fee, the second reaching the September extension, and DHS has proposed a separate $103,265 fee.
- Conrad 30 faces a cutoff: USCIS warned in October 2025 that physicians entering J-1 status after the Conrad 30 provision lapsed would lose access to the waiver unless Congress acted.
Psychiatry offered 2,516 residency positions in this year’s Main Residency Match, 469 more than in 2022, and filled 97.4 percent of them, according to the National Resident Matching Program. Sixty-five positions went unfilled, up from eight a year earlier. Across all specialties, foreign-born international medical graduates who needed visa sponsorship matched to first-year positions at 54.4 percent, the lowest rate in five years, while those who held permanent residency matched at 67.9 percent and U.S. citizens who trained abroad matched at 70 percent, the NRMP reported.
Behind those results is a workforce trained substantially abroad. A study in Academic Psychiatry drawing on 2020 American Medical Association and Educational Commission for Foreign Medical Graduates data found that international medical graduates accounted for 29 percent of active psychiatrists, compared with 23 percent in all other specialties. Many were U.S. citizens who studied overseas, often in the Caribbean, and more than 30 percent of foreign-trained psychiatrists had graduated from schools in India and Pakistan.
The specialty’s growth has been steady. The 2,516 positions represent a 22.9 percent increase since 2022, and 30 new psychiatry programs joined the Match this year. The number of non-U.S. citizen applicants also grew in 2026, even as their overall first-year match rate fell to 56.4 percent.
Their share of incoming psychiatry residents had already been falling before the current visa dispute. International graduates took about 30 percent of psychiatry matches in 2013 and 16 percent in 2023, Psychiatric News reported, and a psychiatrist quoted in that coverage warned of potential workforce challenges for public sector and rural positions. That year, 351 U.S. and non-U.S. international graduates matched into psychiatry, out of 2,143 matched applicants.
Where the H-1B Fee Stands After a Court Ruling and a Proclamation
The September 2025 proclamation required a $100,000 payment with new H-1B petitions filed on or after September 21, 2025 for workers outside the United States who lacked a valid H-1B visa. USCIS guidance the next month exempted petitions for people already in the country who change status, extend status, or amend a petition, the American Hospital Association reported. National interest exceptions were to be granted only in extraordinarily rare cases, and the guidance named no industry, health care included, for categorical relief, according to an analysis by Vorys. To qualify, the homeland security secretary had to find that a worker’s presence served the national interest, that no American worker was available for the role, that the worker posed no security threat, and that requiring the payment would significantly undermine the national interest. Beneficiaries whose in-country petitions were approved would not become subject to the fee by traveling abroad later.
Courts have since taken the payment off the table, at least for now. On June 8, U.S. District Judge Leo Sorokin in Massachusetts vacated the agency actions implementing it in California v. Mullin, then briefly stayed his own ruling while the government appealed. After the First Circuit declined on July 24 to keep that pause in place, USCIS said on July 28 that it would stop collecting the fee, the American Immigration Lawyers Association reported. Merits briefing in the First Circuit was expected to conclude October 16.
The White House extended the proclamation on September 18 through September 21, 2027. Twelve days later, U.S. District Judge Haywood S. Gilliam Jr. in the Northern District of California vacated the agency policies and enjoined their enforcement, including as applied to the extension, in Global Nurse Force v. Trump, a case whose plaintiffs included a nurse staffing company, Forbes reported. Employers had paid the fee for only about 700 workers, according to the same report. Not every court has agreed, and Ogletree notes that conflicting rulings leave room for further review.
A second measure is moving through rulemaking. On August 25, DHS proposed a $103,265 fee on H-1B petitions subject to the annual cap, including change-of-status requests from people already in the United States; public comments closed September 24. The American Hospital Association asked DHS on September 23 to exempt health care workers, after asking last year for the same relief from the $100,000 payment, according to AHA.
Cap status decides who that proposal would reach. The annual H-1B cap allows 65,000 new visas plus 20,000 for holders of U.S. advanced degrees. Universities and their affiliated nonprofit entities file cap-exempt petitions, which places many academic psychiatry departments outside it, while independent psychiatric hospitals and physician groups generally file cap-subject petitions.
Conrad 30 and the J-1 Route Many Residents Use
Many international residents train on J-1 exchange visas rather than H-1Bs, and the J-1 carries its own constraint: physicians must generally return home for two years after training unless they obtain a waiver. Through the Conrad 30 program, each state can recommend up to 30 waivers a year for physicians who commit to three years of full-time work in underserved areas, as Utah’s program description lays out.
Congress renews that authority periodically. When the federal government shut down on October 1, 2025, USCIS posted an alert stating that unless Congress extended the provision, people admitted in or acquiring J-1 status on or after that date would not be eligible for a Conrad 30 waiver, while those who held J-1 status by September 30 remained eligible. Reauthorization bills introduced in 2025, S. 709 and H.R. 1585, would extend the program. Because psychiatry residencies run four years, the physicians most exposed to the cutoff are still early in training.
Conrad 30 placements are, by design, in shortage areas and in settings that serve underserved patients.
Recruiting Psychiatrists Under Unsettled Immigration Rules
Behavioral health employers currently pay no H-1B fee for a new hire, but the planning horizon is short. A psychiatrist recruited from abroad through a new petition could again carry a $100,000 payment if the government overturns both rulings, and a cap-subject petition could carry $103,265 if DHS finalizes its proposal, with the two measures operating independently. A September 18 executive order separately calls for closer federal review of H-1B filings, according to the Yale summary.
Employers recruiting from the domestic pool face their own arithmetic. Psychiatry left 65 residency positions unfilled this year after adding 30 programs, and the visa-sponsored applicants who once filled more of those slots are matching at lower rates than permanent residents and U.S. citizens who trained abroad.
The exposure is uneven by state. In the Academic Psychiatry study, international medical graduates made up more than 40 percent of active psychiatrists in both Florida and New Jersey.
