New $100K skilled-worker H-1B visa fee could mean fewer Indian doctors to treat rural residents

One in five immigrant doctors in the U.S. is of 
Indian origin. (Photo via BBC News)

The Trump administration's new $100,000 skilled-worker H-1B visa fee could leave fewer Indian doctors to treat rural populations. "One in four doctors providing care in the U.S. are foreign-trained, and recent data shows that most of them practice in the vast, underserved rural areas where American graduates are reluctant to work," reports Savita Patel of BBC News.

For the roughly 50,000 India-trained physicians currently working in the U.S., the new visa fee does not apply; however, there are worries around "whether the steady supply of Indian medical professionals to the U.S. would continue in the future," Patel explains. "According to research, one in five immigrant doctors in the U.S. is of Indian origin."

And while the administration may eventually decide to exempt medically trained workers from the new fee, currently, "there is no indication that any category of workers, including those in the medical field, has been exempted," Patel reports.

The American Medical Association asked the Secretary of Homeland Security, Kristin Noem, to reconsider the new fee, "emphasizing that the fee hike could discourage hospitals from hiring H-1B doctors, affecting future supply pipelines and limiting patients' access to care in communities that need it the most," Patel adds.

Supporters of the fee hike insist it will keep "American jobs for Americans," Patel adds. But research on which jobs foreign medical workers take shows they are filling positions that American doctors don't want -- in regions that are "remote and low-income."

Given the financial straits many rural hospitals are already in, "any hike in the fee would make it harder to bring in new clinicians from abroad," Patel writes. Dr. Bobby Mukkamala, president of the AMA, told Patel, "We have heard from health systems who say this fee would be devastating."

Rural hospitals tap into high schools to meet ongoing staffing challenges

Ballad Health is one of several rural-serving 
hospitals training high school students.

Ballad Health is a rural hospital system in Tennessee that, like many rural hospitals, spends millions of dollars a year paying traveling nurses to cover staffing shortages. To address its recruitment woes, Ballad is working with area high schools to train its next generation of medical care workers, reports Te-Ping Chen of The Wall Street Journal. 

Ballad's high school training academy includes students from "five northeast Tennessee school districts," Chen writes, "The first batch of 200 students will graduate in 2029, with their licensed practical nurse credentials and be eligible to work right away at Ballad, earning $23 an hour." 

Building and implementing a medical training academy for high school students is time-intensive and expensive, so Ballad Health partnered with Bloomberg Philanthropies, which "last year announced it was pumping $250 million into 10 programs in states including Tennessee, Texas and North Carolina to create a high school-to-healthcare pipeline," Chen explains. 

Ballad isn't alone in its staffing struggles, and as the baby boomer generation ages, demand for medical care staffing is expected to grow. Chen reports, "Human resources advisory firm Mercer projects a deficit of 100,000 healthcare workers by 2028."

Since 2006, Baystate Health system, which serves rural populations in western Massachusetts, has invested in a "high-school career program for jobs such as respiratory therapist and sterile processing technician," Chen adds. "Many participants have gone on to pursue additional training, and more than 900 have ended up working for Baystate in the past decade."

If Congress doesn't extend enhanced health care tax credits, 4 million rural Americans could face steep premium hikes

Average health care premium comparison before and after ACA credits for 10 'farm states.'
(Robert Woods Johnson Foundation graph)

Without the Affordable Care Act's enhanced tax credits, roughly four million rural Americans could see significant increases to their health care insurance premiums. Last year, the Health and Human Services reported that 17% of individuals who purchased insurance through the ACA marketplace were rural residents, reports Chris Clayton of Progressive Farmer.

While Washington lawmakers focus on eliminating programs that could use American tax dollars to pay for health insurance for illegal immigrants, "there is less talk about how much rural America relies on those tax credits," Clayton explains. "The tax credits have been a major driver for reducing the number of uninsured Americans."

In 2024, the Robert Wood Johnson Foundation reviewed "enrollment of Medicaid and marketplace policies in ten 'farm states,'" Clayton reports. "In that study, eight states -- all but Iowa and Kentucky -- showed more than 5% of residents were enrolled in ACA marketplace policies."

Without ACA enhanced tax credits, health insurance premiums may be out of reach for many rural Americans. According to the article, an individual making $35,000, with enhanced tax credits, would pay a health care premium of $1,033 per year. Without ACA credits, the premium jumps to $2,615 annually, representing a $1,582 increase.

"Overall, the enhanced tax credits saved rural enrollees an average of $890 per year, about 28% more than their urban counterparts," Clayton reports.

Class-action suit against The Salvation Army could help addiction sufferers access the two most effective medical treatment drugs

The Salvation Army is best known for
its holiday bell ringers. (Adobe photo)

Managing up to 25,000 Christmas bell ringers isn't the only thing The Salvation Army does. The charity also runs addiction treatment facilities whose care is at the "center of a legal fight that could set a precedent for all Americans seeking treatment for opioid addiction using two common and effective medications, methadone and buprenorphine," reports Lev Facher of STAT News.

The Salvation Army addiction facilities prohibit participants from using methadone and buprenorphine, despite the fact the "two medications are widely used to treat addiction and are vastly safer than the drugs they are meant to replace, like heroin or fentanyl," Facher explains. The class-action suit alleges its plaintiffs were "denied access to addiction treatment services because of their use of the medications."

The two drugs form the only medical treatment shown to effectively help addiction sufferers stop using opioids. The drugs also prevent severe fentanyl withdrawal, which can be physically and mentally excruciating.

Methadone and buprenorphine are often viewed by many Americans as "little better than street drugs," Facher reports. "As STAT found in the investigative series "The War on Recovery," many recovery-focused groups — including The Salvation Army and other rehabilitation centers, as well as 12-step recovery organizations like Narcotics Anonymous — remain opposed to the medications’ use despite the overwhelming evidence of their medical benefit."

Officials with The Salvation Army did not respond to requests for comments, according to Facher. 

Janet Herold, an attorney with the nonprofit Justice Catalyst Law, which sued The Salvation Army, told Facher, “The case has the potential to quite dramatically change the access situation for people with opioid use disorder." Facher adds, "The ongoing lawsuit, Herold said, could set a precedent that leads more treatment providers to offer the medications regardless of their ideological objections."

According to Facher's report, the "judge's ruling relies in part on the Rehabilitation Act of 1973, legislation that bars any group receiving federal financial assistance from discriminating against an individual solely on the basis of their disability."

Understanding what pharmacy benefit managers are reveals flaws and solutions in U.S. drug pricing and selling system

Not all PBM savings are passed along to members.
(Adobe Stock photo)

Despite a deluge of news information discussing the unfair pricing practices of pharmacy benefit managers, what they are and what they do may still be a mystery. James B. Rebitzer, an economics professor at Boston University, provides some answers in his Q&A for The Conversation.

What are pharmacy benefit managers?
During the 1960s, PBMs "became essential middlemen [companies] between drugmakers and the many insurers, employers and government entities who purchase drugs on behalf of their members. . . . These companies negotiate price, affordability and access to prescription drugs. They do this by operating and designing formularies, which are lists of drugs that insurers cover.

Formularies assign drugs to different tiers that determine what patients must pay out of pocket to access the drug. . . . Tier placement determines how affordable a medication is to consumers and the effective drug price that insurers pay. . . .The price at which the PBM obtains the drug for its clients is the net price – the list price minus the drugmaker’s discount. . . . If a drugmaker increases its rebate, the net price falls, even if the publicly posted list prices remain high. This is why focusing on list prices to determine the cost of a drug can be misleading."

Are PBMs working to decrease their clients' costs or increase their profits?
Both. "If the contest for formulary placement works as it should, competition compels drugmakers to offer substantial discounts off the published list price. As a result, insurers and consumers benefit from a reduced net price for drugs. However, formulary competition can be undermined in various ways. . . . Competition within the formulary can also be distorted when drugmakers post very high list prices. This artificially inflates rebates for PBMs without lowering net prices for insurers and other parties."

How does market competition figure into PBM activity?
"The current regulatory environment in the U.S. tolerates overly large PBMs that engage in anticompetitive practices to accumulate excessive profits. Without strong competitors, dominant PBMs are free to charge their customers high fees and keep a larger portion of drugmaker rebates for themselves. . . . In theory, this problem should be self-correcting. . . . High profits should attract new competitors into the industry." But the chances for scrappy upstarts to survive are also limited by the industry's current PBMs' dominance.

Who are the villians?
The concentration of power is the problem. "If we didn’t have PBMs, we would need to invent them – or something like them – to obtain reasonable prices on patented drugs. But the concentration of market power among a few companies threatens to dissipate the value they create. A more competitive and transparent market for PBM services will help keep that contest fair and transparent – to the benefit of customers and society. . . . In that sense, PBMs aren’t the villain. Too much market power in too few hands is the problem, and that’s something more competition, sensible regulation and vocal consumers might fix."

Working-age rural residents are dying at 'wildly higher rates' than their urban counterparts; cause is undetermined

Photo by M. Vistocco

U.S. mortality rates can fall into two very different camps -- rural working-age death rates and everyone else's death rate. "Rural Americans age 25 to 54 — considered the prime working-age population — are dying of natural causes such as chronic diseases and cancer at wildly higher rates than their age-group peers in urban areas, according to a new report from the Agriculture Department's Economic Research Service," reports Jazmin Orozco Rodriguez of KFF Health News.

To compare the two groups, "USDA researchers analyzed mortality data from the Centers for Disease Control and Prevention from two three-year periods — 1999 through 2001, and 2017 through 2019," Rodriguez explains. "In 1999, the natural-cause mortality rate for rural working-age adults was only 6 percent higher than that of their city-dwelling peers. By 2019, the gap had widened to 43 percent." 

In reviewing demographic differences, Native American women fared the worst, but overall, a link between younger rural deaths and a lack of Medicaid expansion could be part of the cause. "USDA researchers and other experts noted that states in the South that have declined to expand Medicaid under the Affordable Care Act had some of the highest natural-cause mortality rates for rural areas," Rodriguez reports. "But the researchers didn’t pinpoint the causes of the overall disparity."

Another possible connection could be the lack of rural health care options and rural hospital closures. "Alan Morgan, CEO of the National Rural Health Association, and other health experts have maintained for years that rural America needs more attention and investment in its health care systems by national leaders and lawmakers," Rodriguez adds. "It’s unlikely that things have improved for rural Americans since 2019, the last year in the periods the USDA researchers examined. The coronavirus pandemic was particularly devastating in rural parts of the country."

2023 was a tough year in many ways, but saw significant positive developments in science and medicine

The first pill to treat postpartum depression was
approved in 2023. (Photo by Hollie Santos, Unsplash)

Despite wars, the most mass killings since 2006, and the hottest average temperatures in human history, "2023 also was a year with significant positive developments, including in scientific research and medicine," report Victoria Bisset and other Washington Post staff members. Not only does some good news about the past year provide comfort, the Post points out that "research has indicated that uplifting news can provide an emotional buffer against distressing news and feelings of hopelessness — and even encourage optimism or action." Here are some things the Post listed:

The World Health Organization approved a new malaria vaccine that has been shown to be much more effective than the only previous vaccine against the potentially deadly disease. The U.S. has about 2,000 cases of malaria each year, most of them contracted in other nations.

The Food and Drug Administration approved the first pill to treat postpartum depression, which affects up to one in five women who can "experience intense hopelessness and, in rare cases, psychosis — and it can last for years," the Post notes. "The new drug is taken once a day for two weeks and, unlike the existing treatment of an IV injection that may take as long as 60 hours to administer in a health-care setting, it can be taken at home."

The FDA also approved two gene-therapy treatments for sickle-cell disease, "a rare and debilitating condition that affects around 100,000 Americans, most of them Black. The disease causes extreme, constant pain and can drastically cut the life span of those affected," the Post notes. "Both are intensive, expensive procedures — and require chemotherapy, which has significant side effects. But patients who have received the treatments have spoken of its profoundly beneficial impact on their lives."

Scientists made progress in understanding dementia, the Post reports. One study "suggested that lifestyle habits, including regular mental and physical activity, eating a healthful diet, and regular social contact were linked with a slower rate of memory decline," the Post reports. "Another found that living in areas with more natural green spaces was associated with lower rates of hospital admissions for diseases including dementia, while separate research indicated that the use of hearing aids could cut the risk of cognitive decline by nearly half."

Meanwhile, the FDA approved, for the first time, a drug that modestly slows Alzheimer’s disease. While difficult questions about safety, effectiveness and cost remain, many neurologists say that having a drug that slows Alzheimer’s is nonetheless a milestone after years of failed trials.

The world is full of lonely people -- part of the antidote is changing how people react to this universal emotion

Loneliness is a human experience and an internal
message. (Photo by Kristina Tripkovic, Unsplash)

Being lonely has become so widespread that globally, one in four adults report feeling sad and alone. Medically, continued loneliness can take a severe toll on people's health, yet "pangs of loneliness aren't catastrophic. In fact, they're nearly universal. What's critical is how people respond to these feelings when they arise," reports Allison Aubrey of NPR. Commenting on the best way to respond to feeling lonely, Dr. Jeremy Nobel, a primary care physician and author of the new book Project UnLonely, told Aubrey, "Just like thirst is a signal you need hydration, loneliness is a signal that you need human connection."

Nobel's book creates a path to "using creative expression as a means to communicate," Aubrey writes. "When there's not a prescribed way to 'belong,' finding connection can be tough. Many people are hesitant to put themselves out there, or they have a hard time communicating what's on their minds. 'This is where the arts can be very powerful because they act as a catalyst to make it easier,' Nobel says. . . . Drawing a picture may seem like a solitary act, but it can be a bridge to connection, a way to express what's on your mind."

Viewing or creating art can improve mood.
(Photo by Jill Dimond, Unsplash)

Nobel has long believed in creative expression as a natural partner to medicinal treatment. "Some of his earliest work was with active-duty service members and veterans returning from Iraq and Afghanistan with post-traumatic stress," Aubrey explains. "They gathered in small groups to engage in artistic expression and mindfulness activities." Nobel told her, "People began telling us that not only were they less stressed out, but they felt more connected to each other, something I later realized was addressing a certain kind of loneliness."

From culinary arts to poetry to gardening, there are ways humans can use curiosity and creative discovery as a way to connect. "Project UnLonely now partners with community-based organizations to develop evidence-based creative expression programs, which can include music, painting, drawing and beyond," Aubrey adds. "Research shows making art or even viewing the work of other people reduces levels of the stress hormone cortisol. It also increases levels of the feel-good hormones, including dopamine, endorphins and oxytocin."

While it's hard for loneliness to prevail in the face of curiosity and encouragement, people may struggle to get started. Click here for five ideas that will help overcome those fears.