As of September 2025, 18 states have enacted laws creating alternative licensure pathways for internationally trained medical graduates (IMGs) to practice medicine without completing a U.S. residency. This change comes as policymakers are realizing a projected shortfall of up to 86,000 doctors by 2036. Over 30 states — from the West Coast to the East, from red to blue — have proposed new IMG accreditation legislation. We are witnessing the largest rewiring of the physician workforce since the development of the NRMP in 1952, yet few have truly grappled with the impact of an expanded second labor market for doctors. Just as the tech industry once turned to global immigration talent and the H-1B visa, allowing employers to sponsor foreign professionals for 3-6 years of employment, opening a path to naturalization, I believe medicine may be on the cusp of its own “H-1B moment,” with profound effects on all stakeholders. To say up front: this piece will not be a critique of internationally trained physicians. It’s a look at incentives — because when you open a parallel pipeline governed by different economic rules, labor markets do what labor markets do.
18 States, 18 Rulebooks
Let’s begin by examining the text of the legislation passed to date. Broadly, the common framework is that an experienced IMG can obtain a provisional license to practice under supervision in under-served areas and after a certain period of satisfactory supervised practice, convert to a full, unrestricted license. Take Florida’s 2024 SB 7016 for example. It requires candidates to have “completed a residency or substantially similar postgraduate medical training ... as determined by the board.” Or Arkansas’ notably permissive 2025 SB 601, which only requires “passing the exam used by the ECFMG” and “actively [practicing] medicine during the four-year period preceding.” Or Texas’ more strict 2025 HB 2038 (aka the DOCTOR Act) which hinges on two years of practice in an academic setting plus two years in underserved areas.
In practice, these statutes do not form one pathway but 18. Eighteen rulebooks studded with “as determined by ...” clauses that punt key decisions to non-neutral stakeholders, making outcomes vulnerable to local politics and lobbying and igniting regulatory arbitrage. In 2025 especially, the policy has trended toward maximally permissive, with states dropping the requirement of a foreign residency program and relying on board approval and documented claims of successful practice in an applicant’s home country. This ignores that such claims are hard to audit in practice: verifying “four years of continuous practice” across fragmented registries, private hospital HR letters, and state medical councils in countries such as India or Mexico is nontrivial and uneven. Just as importantly, many laws rely simply on documentation as the critical chokepoint: an “offer of employment” in one state, a board-approved assessment program elsewhere. Each a locus where lobbying, local politics, and pay-to-play business dynamics can shape who is approved or denied.
On The Business of Health Care
Whenever there is disruption in a regulated industry like health care, private equity and venture capital tend to perk up. A fragmented system raises the risk of a race to the bottom for licensing scrutiny and a race to the top for profit as businesses intrude into the labor market of health care. Aside from clear advantages to historically hard-to-staff areas (rural hospitals, community health centers, and telemedicine firms stand to benefit), less obvious, new business niches are also likely to grow from this shift. Credentialing services will be in high demand to verify and translate diverse foreign qualifications in a way that satisfies ambiguous board, politician, and insurance company requirements: an area ripe for consulting. Similarly, physician placement agencies specializing in international hires may emerge or expand, acting as intermediaries to connect overseas talent with U.S. health care employers. Legislation today is unclear: Which hospitals qualify as “participating facilities”? Which foreign programs meet “substantial similarity”? How strictly will “supervision” be defined? As such, entrepreneurial health systems can draw on the tech H-1B playbook to answer these questions: sourcing candidates, guaranteeing offers, and navigating immigration paperwork to control IMG supply. Layer in a redesign of the physician’s day-to-day responsibilities (extend panels, allow tele-supervision, or mix provisionally licensed physicians with mid-levels under a single supervising attending) and you have a repeatable pipeline with lower average labor cost.
Ultimately, large hospital systems and private equity-backed platforms are best equipped to lobby, invest in compliance, and complete the paperwork required for state approval. They also have access to attending educators who can be made to supervise multiple IMGs in these new “residency-lite” programs with unclear performance criteria. At the extremes, if statutes make it easier to staff rural hospitals and urgent care networks with sponsor-tethered physicians, expect PE to string together multi-state platforms that route volume to IMG-friendly jurisdictions. The result is further soft capture of physician labor and employment opportunities. If you’re a practicing physician in private or small-group settings, that dynamic does not bend in your favor when it comes to wage setting.
On the Labor Market
For foreign trained physicians, this is a remarkable opportunity, but not without downsides. One criticism of the H-1B system in tech has revolved around sponsorship: tether a worker’s right to work to a specific employer, constraining their ability to seek other employment, and bargaining disappears. Many state IMG laws seem to replicate that leverage with service requirements, employer notifications within five days of job changes, and “practice only at the sponsoring facility” clauses. As seen in tech, the most concerning trend would be the proliferation of nebulous organizations to sponsor the H1-B visa of these valuable physician employees, taking portions of their salary as payment and therefore depressing wages. Even where statutes promise full conversion after two or three years, those early years matter as compensation norms can become set, lower titles invented, and internal pay bands justified with risk language. The 18 rulebooks tend to punt questions of payment of IMGs and other critical questions to hospitals themselves, which do not have benign incentives. Since Tennessee passed its first-of-its-kind IMG law in 2023, some researchers have proposed requiring hospitals to set standard salaries for provisionally licensed IMGs (PL-IMGs) based on experience. Yet, two years and 17 states later, no notable frameworks have materialized.
For U.S.-trained physicians in a health system straining under clinician burnout, having more hands on deck is likely to reduce the burden on overworked doctors. Yet it’s impossible to ignore the undercurrent of competitive dynamics this introduces. U.S.-trained physicians have long enjoyed a relatively protected labor market once they clear the substantial hurdles of medical school, residency, and board certification. While physician labor markets are not perfectly elastic, they’re also not immune to supply. We may see limits on how quickly these programs scale up to avoid any perception of “flooding” the market — and so far we have seen slow licensing and adoption of foreign-trained physicians. There’s also the question of specialization. Current specialty board barriers would result in existing primary care doctors feeling the impact first. However, I am doubtful that such barriers will remain in any meaningful capacity in our health care system under strain as hospitals and businesses begin to reap the benefits of expanded supply.
On Patients and Communities
For patients, especially those in underserved communities, the prospect of more doctors in the system is welcome. Average wait times for care are rising, now at 31 days across all specialties, and experienced foreign physicians could help improve access. Patients may also benefit from the diversity of experience that international physicians bring. Many IMGs have treated diseases which are now becoming endemic to the U.S. as vaccine hesitancy and climate change loom large. Some may bring native multilingual proficiency. And having a doctor who understands how to work with limited resources can be important in rural America. However, American health care is substantially different, even from peer nations, in the types and brands of medications we use, our gold-standard guidelines and practices, the day-to-day practice, and the cultural expectations of patients. It is critical that patients are not forced to compromise on these metrics and that quality is assured. So far, states are indeed requiring things like passing the USMLE exams, English proficiency tests, and close oversight — yet we must watch for misaligned incentives resulting in the aforementioned race to the bottom. In the long run, success will be measured by patient outcomes: if these programs help close care gaps without compromising quality, it will validate the approach and likely spur more states to join in.
On Health Care
Not since the 1950s has the medical establishment seen such a potential upheaval in how physicians join the ranks. From one state to 18 and soon to 30, we are witnessing a nationwide movement to rethink licensure and tap into a global supply of healers. With a clear examination of the incentives at play, we can work to ensure that this “H-1B moment” for health care delivers on its promise for American health care.
Author’s Disclaimer: A new policy proposed by the Trump administration — of a $100,000 fee per person for H-1B visas — while this piece was being written could affect a hospital’s ability to hire IMG residents. However, it’s unlikely to substantially impact IMG attending physicians, given their higher salaries. With discussions already underway to exempt health care workers from this H-1B fee, this article’s predictions should remain accurate, though health care policy is in a period of significant flux.
Aditya Jain is an MD student at Harvard Medical School, and a researcher on applications of AI in medicine at the Broad. He is interested in the business of health care and its intersection with technology and policy. More of his writing can be found on Substack @adityajain42. Aditya was a 2023–2024 and a 2024–2025 Doximity Op-Med Fellow, and continues as a 2025–2026 Doximity Op-Med Fellow.
Illustration by April Brust
