Physician and hospital groups are hopeful Congress will approve thousands of additional Graduate Medical Education slots this year which, if successful, would mark one of the biggest expansions to the program seen in decades.
Citing a looming physician shortage, doctors and providers have lobbied Congress for more than a decade to increase the number of residents Medicare helps pay to train. That number has been frozen since 1996 until Congress approved an additional 1,000 slots in December.
Lobbyists say that was the catalyst needed to break a decades-long resistance to expanding the program, with provider groups pushing for an additional 14,000 slots this year.
"It was COVID I think that spurred everyone into seeing we can't have this artificial cap in place. It's too restrictive on our healthcare system," said Jon Cooper, senior vice president of government affairs, communications and public policy for the Greater New York Hospital Association.
There are talks on Capitol Hill about including the more funded GME slots in the infrastructure packages Congress is working on, though discussions are still in the early stages.
"We think the time is right, the momentum is there, and we're hoping it's included," Cooper said.
The Association of American Medical Colleges projects a shortage of 54,100 to 139,000 physicians by 2033, citing retirements, burnout, and a growth in the aging population that needs more medical care.
The GME push has some influential backers in Congress including Senate Majority Leader Chuck Schumer (D-N.Y.) and House Ways & Means Committee Chairman Richard Neal (D-Mass.), both strong allies of the hospital industry.
Any infrastructure provisions that touch on Medicare spending would need to move through Ways & Means, and Neal has been pushing hard on the GME issue, according to lobbyists and his staff.
"Chairman Neal is concerned about the future of the physician workforce and wants to be sure we are investing now to build one that matches the diversity of our country," a Neal spokesperson told Modern Healthcare. "He's looking into a visionary policy to create the pipeline to practice that's needed to bring more people from underrepresented groups into the fold and support them throughout their training."
Proposals from Sens. Robert Menendez (D-N.J.), John Boozman (R-Ark.), Schumer, and Rep. Terri Sewell (D-Ala.) would add an additional 14,000 slots over a seven-year period, and target some of those positions to rural hospitals, areas with shortages of health professionals and hospitals training over their GME caps.
Those targets were key to getting the 1,000 slots passed in December, lobbyists say, and similar targets are included in the new bills.
A 2018 report from the Government Accountability Office found that most residents train in certain urban centers in the northeast. And 99 % of spending on GME training was used to support training in urban areas. It's likely more than 1% of spending goes to training in rural areas, GAO said, but the lack of data makes it difficult to know for certain.
Now as lawmakers are debating what to include in a multitrillion-dollar infrastructure package, physician groups are arguing that addressing shortages in the healthcare workforce should be part of it.
"As we see it at the AHA, infrastructure means bricks and mortar, roads and bridges, and broadband, but it also means investment in human resources that provide for the most urgent needs of the nation," said Priscilla Ross, senior associate director for federal relations at the American Hospital Association. "I think Congress as a whole sees this as beneficial to meeting the growing needs of the patients they represent."
But cost may be an obstacle.
There are competing priorities for what should be included in an infrastructure bill. If Democrats choose to use reconciliation—a budget maneuver that is immune to the filibuster and only needs a simple majority to pass—they will face additional cost restraints.
Training residents is expensive. Lawmakers froze the number of GME slots in 1996 fearing a oversupply of residents as hospitals added more and more positions with no restrictions on how many Medicare would help pay for.
In 2015, the most recent year data was available, Medicare spent more than $10 billion on 88,000 GME slots, according to the GAO.
"I think there's always cost concerns. We certainly recognize that this is a significant investment we're asking Congress to make but I'm always concerned about what's the cost of not acting and what's the impact on the health of our nation and what it means for access?" said Leonard Marquez, senior director of government relations and legislative advocacy at AAMC.