HMN 2026: How Medicare residency expansion misses rural and primary care targets,

A new JAMA study finds that federal efforts to expand the physician workforce fall short for primary care and rural communities, despite clear policy goals. The findings raise pressing questions about whether current implementation strategies can effectively address longstanding physician shortages across the U.S.

Researchers examined how programs distributed 1,000 new Medicare-funded residency positions and found that most did not go to the areas with the greatest need.

The U.S. faces a significant and growing physician shortage, especially in primary care and psychiatry and in rural communities. These shortages, especially in rural areas, limit access to health care and worsen health outcomes. Congress passed two laws in 2021 and 2023 to address the problem by adding Medicare-funded residency slots, with clear goals to support shortage specialties and underserved areas, including a 10% rural-area allocation requirement.

A team led by the Harvard Pilgrim Health Care Institute tracked how programs allocated 1,000 new positions between 2023 and 2025. They analyzed national data and compared results with a 2021 baseline to measure whether the programs met the policy goals.

“We found that new residency positions are not consistently reaching rural areas or supporting primary care as intended,” said senior author Hao Yu, Harvard Medical School associate professor of population medicine at the Harvard Pilgrim Health Care Institute.

Key findings include:

• Psychiatry growth outpaces primary care: While psychiatry captured more than half of new slots in 2023 and grew by 12.5% since 2021, primary care’s share dropped from 52% to 31.5%.
• Shortage area progress starts strong, wanes quickly: Programs placed all new slots in shortage areas under the 2021 law, but that share dropped to about 82% under the 2023 law.
• Underserved communities left behind: Programs never met the 10% rural target and dropped to just 1% in the latest round of allocation—far below what the laws intended.

“Expanding training slots alone is not enough. How programs distribute those slots matters for addressing physician shortages,” said lead author Tarun Ramesh, 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.”

The work builds on the authors’ growing body of evidence highlighting shortfalls in the health care workforce and the effectiveness of solutions put forward to mitigate them. This study, they say, underscores a broader lesson: Designing policies to address physician shortages is not sufficient on its own. Implementation, distribution and sustained infrastructure investment are equally critical to achieving health care workforce equity.

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