The Consolidated Appropriations Act, 2021 (CAA), enacted on December 27, 2020, is reportedly the longest bill in congressional history. Many provisions impacted family medicine, but this post highlights changes to one of the most important federal physician training programs—graduate medical education (GME)—and ACOFP’s work to further grow the primary care physician workforce.

GME Primer

Federal GME programs are the largest source of healthcare workforce spending.1 GME funding under the Medicare program is primarily made to teaching hospitals with accredited medical residency programs. This funding is intended to cover Medicare’s share of these programs’ costs, including direct costs, such as resident stipends, teaching physician salaries and other costs associated with operating a residency program, as well as indirect costs related to higher patient care costs in teaching hospitals compared to non-teaching hospitals. Given the importance of GME funding for training physicians, policy changes to the program can have long-term effects on the future physician workforce.

Key Changes Impacting GME in the CAA

The CAA made the following significant changes to GME:

  • Provides an additional 1,000 Medicare-covered GME residency positions, with at least 10% going to rural hospitals (or hospitals treated as located in a rural area), hospitals in states with new medical schools and hospitals that serve health professional shortage areas. The new slots will be available beginning 2023 with up to 200 slots awarded each fiscal year. However, a hospital cannot receive more than 25 full-time equivalent (FTE) slots through this distribution.
  • Directs the U.S. Department of Health and Human Services (HHS) to prescribe rules regarding the Medicare GME Rural Training Track (RTT) program for greater flexibility for certain hospitals participating in the RTT. Specifically, the new flexibilities will be available for cost-reporting periods beginning on or after October 1, 2022, for non-rural hospitals that have a medical residency program where 50% of the RTT occurs in a rural area.
  • Allows certain hospitals that train a limited number of residents for short-term rotations (i.e., less than 1.0 FTE in an approved medical residency training program in a cost-reporting period) to operate without being negatively impacted by the establishment of an FTE resident cap or per resident amount (PRA). For hospitals that establish a new medical residency program, the HHS secretary will not set a resident limit until the hospital has trained at least 1.0 FTE during a cost-reporting period in the new residency program. Finally, the CAA allows for a one-time reset of the FTE resident cap and PRA for hospitals with low resident counts.
  • Authorizes funding for the Teaching Health Center GME program through 2023 at current funding levels of $126.5 million per fiscal year.

In past years, lawmakers were reluctant to update GME for several reasons, including the belief that the Medicare GME program is inefficient and concerns about increases to federal spending. However, the COVID-19 pandemic has highlighted the physician shortages in the United States and the need to grow the physician workforce over time.

Looking Forward

The policy changes in the CAA will help grow the physician workforce and are a step in the right direction to address workforce shortages. ACOFP has advocated for expanded GME funding and applauds Congress for including the GME provisions in the CAA. However, more work is needed to ensure patients have access to high-quality primary care.

As more physicians reach retirement age and fewer medical students pursue a career in primary care, it is important to act now to bolster the primary care physician workforce. ACOFP is in the process of finalizing its 2021 advocacy principles and priorities to advance several policies to improve the primary care physician workforce, including:

  • Equalizing payments for primary care physicians and other specialty physicians
  • Increasing financial support for rural training programs
  • Supporting loan forgiveness and student loan deferment programs that incentivize medical students to pursue careers in primary care

Using these priorities as a foundation, ACOFP looks forward to working with Congress and the administration to advance policies that grow the primary care workforce, ensuring patients have access to high-quality primary care for years to come.


  1. Medicare Graduate Medical Education Payments: An Overview. Congressional Research Service. Updated February 19, 2019. Available at https://crsreports.congress.gov/product/pdf/IF/IF10960/3

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