Immigrant workers can fill Iowa health care gaps — when the system works

Fadi Yacoub didn’t expect to fall in love with Iowa.

The plan was to complete his medical training in the U.S., then return to Syria, where he was born. But the two years he spent in the University of Iowa’s nephrology, or kidney specialist, fellowship convinced him to stay.

“Iowa is one of those states you really need to come and live in it to appreciate truly,” Yacoub said. ”It felt like home, and I said, I want to stick around.”

  Buy Photo

Rather than go back to Syria, Yacoub applied for an H-1B visa, a temporary visa that allows employers to recruit well-educated employees from abroad for specialized positions, like those in technology or medicine. He got his green card while on the H-1B visa and is now a permanent U.S. citizen and proud Iowan.

However, it may be harder for international physicians like him to make it to the state in the future. In the past, employers paid around $2,000-5,000 to sponsor someone on an H-1B visa. But in September 2025, the White House issued a proclamation that raised the fee to $100,000 for all new H-1B applications.

Recruiting workers on H-1B visas and green cards is part of Iowa health care systems’ strategy to address the state’s nursing and physician shortages. It may be especially useful for Iowa’s rural hospitals — a survey of international medical graduates found 45.6 percent of respondents worked in rural areas. But the increased H-1B visa fee on top of an already complex immigration system could create roadblocks for Iowa health care providers as they scramble to fill the state’s needs.

H-1B doctors bring specialized care to underserved areas

When Yacoub arrived at Compass Memorial Healthcare in Marengo in 1996, he learned he’d have to juggle different roles. In addition to his nephrology responsibilities, Yacoub performed minor dermatologic and orthopedic procedures, worked with pediatric patients and helped staff the hospital’s emergency department.

Yacoub lived in Belle Plaine as part of his visa requirements. He didn’t come to the U.S. on an H-1B visa — he started off on a different program that required him to practice for two years in Syria after completing his residency. Instead, Yacoub successfully requested a waiver that let him stay in the U.S. and work in a medically under served area with an H-1B visa.

Outside of the hospital, Yacoub said he quickly connected with the community in Belle Plaine. By the end of his three years at the hospital, he knew the whole town.

“I still have friends in Belle Plaine,” Yacoub said. “Really too small area to be able to stay there. I wouldn’t have minded it, but just too small.”

There weren’t enough patients in the area in need of a kidney doctor for Yacoub to focus on the specialty he loved. So while he was working full-time at Compass Memorial Healthcare — and participating in Rotary Club and acting as the ambulance medical director — Yacoub traveled to Cedar Rapids and Waterloo on the weekends to cover for nephrologists there. When he got his green card, Yacoub relocated to Cedar Rapids for good.

When the increased fee for new H-1B applications was announced, news coverage focused on rural hospitals like the one where Yacoub worked. Chris Mitchell, president and CEO of the Iowa Hospital Association, said the change is the organization’s “issue of the day” given the threat it poses to already understaffed rural hospitals.

However, Joshua Rehmann, chief medical officer for UnityPoint clinic, said rural hospitals aren’t the only ones in trouble.

“I don't think the impact is necessarily urban versus rural because the cost is going to be increased no matter where you recruit this position to,” Rehmann said.

He said small graduating classes in hard-to-recruit medical specialties aren’t enough to meet the state’s demand. What’s more, when students leave Iowa, Rehmann said, they’re unlikely to return. These patterns make it hard to find certain doctors in the state, like OB-GYNs, even in urban areas.

  Buy Photo

Abhishek Pandya, a physician at UnityPoint Clinic Multi-Specialty — Cedar Rapids, is one such doctor. The Canadian is one of a handful of graduates that complete the University of Iowa’s infectious disease fellowship each year.

When Pandya heard about the increased H-1B visa fee, he said his first concern was how it could affect recruitment. Pandya completed his residency in Chicago, where he said salaries were far more competitive than they would be in rural areas.

“Somebody has to take the cost in, either the employer does, or you take it out of the employee,” Pandya said. “It would be a big impact, definitely, in Iowa, which already has an inherent problem with attracting any physicians.”

Nurse staffing agencies hire reinforcements with green cards

Iowa’s health care staffing shortage isn’t limited to physicians. Kara Stineman, associate dean of health, nursing programs at Kirkwood Community College, said a tight squeeze in nursing education is a driving factor in the state’s nursing shortage.

“We have students coming in. We aren't lacking that,” Stineman said. “It's the resources to support those students to get the requirements they need.”

A lack of nursing instructors is a key challenge. Stineman said many nursing school accreditors require nursing instructors to have advanced degrees, but it can be difficult to find a nurse with an advanced degree who works with patients full-time and is interested in adding teaching to their workload.

Nursing degrees aren’t just for the bedside, either. Stineman said some nurses pivot to alternate paths, like working at an insurance company, rather than continue working in hospitals. Lingering burnout from the pandemic, the demanding nature of bedside nursing and the allure of alternate options can make it hard to staff hospitals with the nurses they need to function.

While nurses can come to the U.S. on H-1B visas, some staffing agencies specialize in bringing international nurses to the states on green cards. In 2025, WorldWide HealthStaff Solutions — a direct hire international nurse recruitment agency — said it hired over 500 nurses to work in Iowa health care systems, including MercyOne Genesis and the University of Iowa.

Immigrating on green cards mean these nurses are permanent U.S. citizens by the time they’re hired. There’s no need to switch over from an H-1B visa — but it takes longer for applicants to make it to the states. It can take more than a year for an employment-based green card application to go through.

Moreover, spots are limited. The 140,000 annual cap on employment-based green cards may sound generous, but that’s the size of the pool for all applicants, not just medical professionals. Ann-Rose Johnson-Lewis, director of legal services at WorldWide HealthStaff Solutions, estimated more than 500,000 employment-based green card applications are still waiting to be processed.

Cost matters, but so do retention and red tape

Amanda Bireline, chief operating officer of Cass Health in Atlantic, Iowa, said she’s had little luck trying to hire with H-1Bs or green cards. Cass Health recently lost the only H-1B visa holder it had on staff, an OB-GYN. Bireline said it will take years to fill the gap she left behind, with consequences for Cass Health’s patients.

  Buy Photo

“Often, what we find is our patients will forgo care or attempt to get that type of care from a provider who does not specialize similarly,” Bireline said. “Then before we all know it, we'll find ourselves in a medical crisis which puts strain on our ER and our inpatient units.”

For Bireline, the money isn’t the biggest issue.

“I think any hospital would tell you $100,000 would be worth it to recruit and retain high quality health care professionals,” she said.

Bireline said the effort it took for her small administrative team to go through the paperwork of hiring an international candidate through either method nearly outweighed the benefits of hiring immigrant talent altogether.

And, even though H-1B visas and green cards can bring health care workers to rural areas, that doesn’t mean they’ll stay. H-1B visas are temporary; holders need to apply for a green card if they want to become citizens. They’re not always limited to medically underserved areas, either — the J-1 waiver program that brought Yacoub to the hospital in Marengo only required him to stay for three years. For green card holders, life happens. Cass Health’s OB-GYN relocated to be near a specialized school for her child.

Bireline said hiring staff who don’t stay creates poor quality of care for rural patients who are used to seeing the same family doctor their whole lives.

“One of the worst things that, especially a rural health care provider can do … is bring in providers who then turn over in three years,” Bireline said.

International health care workers don’t threaten domestic job seekers

  Buy Photo

When asked if Iowa’s nursing and physician shortages could be filled by domestic workers only, Mitchell said the answer is no.

“My members are looking for workers everywhere,” Mitchell said. “I think they're looking wherever they can find them, and the place where they can find them and they're willing to come work is through this H-1B visa program.”

When hiring immigrant workers on H-1Bs or green cards, employers have to demonstrate that hiring an international candidate won’t negatively impact domestic workers, and make good-faith efforts to hire someone locally before they can recruit internationally.

“Our primary focus is on training and recruiting nurses from Iowa,” a UIHC spokesperson wrote to The Gazette in an email. “When it is needed, we work with national and international recruitment firms to fill remaining workforce gaps.”

Moreover, when they come to the United States, employers are required to pay international workers the wages that “meet or exceed” the prevailing wage for that job in that area. Mitchell said hospitals would be at a disadvantage if they underpaid these workers — another employer could easily lure them away with a better offer.

A spokesperson for UnityPoint Health, which has locations in Iowa, Illinois and Wisconsin, said it employs 66 physicians through the H-1B visa program, less than 6 percent of the company’s total employed physicians.

Policy efforts could make international recruitment easier

It’s not clear when the full impact of the $100,000 H-1B visa fee will happen. Crucially, it applies to new applications, and not to those already in the U.S. renewing their visa or moving from a J-1 to an H-1B waiver, like Yacoub did.

The American Medical Association, along with more than 50 specialty medical organizations, is petitioning to have health care workers excluded from the fee requirement. Mitchell said the proclamation was intended to target tech workers — health care just got caught in the crossfire.

“I don't think the intent was to threaten access to rural health care by moving forward this policy, and that's what it does,” Mitchell said.

Employment-based green cards are unaffected by the proclamation, but the annual limit hinders its effectiveness. A bill called the Healthcare Workforce Resilience Act was reintroduced in September 2025 to temporarily boost the number of international health care workers allowed into the country. The act would not raise the number of green cards allotted each year. Instead, it would “recycle” unused visas from previous years and allow a one-time infusion of 25,000 nurses and 15,000 physicians into the U.S.

Even though Yacoub is a U.S. citizen now, the H-1B visa program still is proving useful to him.

“I struggled to recruit a nephrologist to my practice for years, until finally we got it,“ Yacoub said. ”Guess what? H-1B visa.“

  Buy Photo

Yacoub said this nephrologist’s children, like his, were born in Iowa. He hopes that she stays and raises them here, that she sees the beauty in Iowa like he did.

“The key is going to be get people here, let them work here,” Yacoub said. “Enjoy Iowa life. And I think significant portion will stay.”

Comments: fern.alling@thegazette.com