Medicare's residency expansion is missing primary care and rural areas

A federal effort to ease the nation's physician shortage by paying for more residency positions is falling short of its goals for primary care and rural communities, according to a research letter published June 15 in JAMA.

Researchers at the Harvard Pilgrim Health Care Institute tracked 1,000 new Medicare-funded graduate medical education positions allocated between 2023 and 2025, drawn from the first four rounds released under a 2021 law and a separate batch authorized by a 2023 law. Most did not land where Congress and federal officials said the need was greatest. The share of slots going to primary care dropped sharply over the period, and the proportion reaching rural counties never approached the target lawmakers set.

The findings come as the physician training pipeline remains tightly capped. The number of Medicare-funded residency positions has long been limited by statute, and only about 2% of them sit in rural areas. Shortages of primary care physicians and psychiatrists are especially acute outside metropolitan areas, where they limit access to care.

To loosen that constraint, Congress authorized new slots in two laws. The Consolidated Appropriations Act of 2021 created 1,000 positions, released in rounds of 200, and required that all of them go to Health Professional Shortage Areas, with 10% reserved for rural areas.

The Consolidated Appropriations Act of 2023 added 200 more and directed that at least half be set aside for psychiatry. Congress left program selection and distribution to the Centers for Medicare & Medicaid Services (CMS), which has said it also prioritized primary care, though it never published a target.

Psychiatry gains as primary care slides

The trend across the 2021 law's rounds is consistent. In the first round, allocated in February 2023, 53% of the positions went to primary care specialties, which the researchers defined as internal medicine, family medicine, internal medicine-pediatrics and pediatrics. By the fourth round, distributed in December 2025, primary care's share had fallen to 31.5%.

Psychiatry trended the other direction. Among the 200 positions funded under the 2023 law, 54.5% went to psychiatry, meeting that statute's requirement. Measured against 2021 residency levels, psychiatry positions grew 12.5%, second only to interventional radiology at 15.8%. Primary care grew 2%.

"We found that new residency positions are not consistently reaching rural areas or supporting primary care as intended," said Hao Yu, Ph.D., the study's senior author and an associate professor of population medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute.

Rural targets went unmet

The 2021 law's 10% rural set-aside was never reached in any round. Rural counties received 6% of the positions in the first round and a smaller share in each round that followed, dropping to 3% by the fourth. The 200 positions funded under the 2023 law sent just 1% to rural areas.

The slots did concentrate in shortage areas, at least at first. Every position funded under the 2021 law went to a Health Professional Shortage Area, as the law required. Under the 2023 law, that figure slipped to 81.6%.

The authors cast the results as a distribution problem rather than an argument against growing the workforce.

"Expanding training slots alone is not enough. How programs distribute those slots matters for addressing physician shortages," said Tarun Ramesh, M.D., the study's lead author and a research fellow at the Harvard Pilgrim Health Care Institute. "Policymakers should strengthen requirements for primary care and rural medicine training to ensure that growth in the physician pipeline translates into care where it is most needed."

What comes next

CMS is preparing the final round of allocations under the 2021 law, and lawmakers are weighing whether to fund still more positions. Without specific carve-outs for primary care and stronger incentives for rural training, the researchers argue, additional slots are unlikely to shift the specialties and places that have lost ground.

The analysis, a cross-sectional study, does have limits. It doesn’t capture how much time residents actually spend in rural practice during their training, and CMS's broad definition of rural means some programs based in nonrural areas may still serve rural populations.

The authors said future research should track whether graduates of the new positions go on to practice primary care and remain in the communities the funding was meant to reach.