New Medicare residency slots miss rural, primary care targets

Clinical takeaway: Expanding residency slots grew the pipeline but did little for primary care or rural access, so workforce gaps in those areas are likely to persist without changes.

Federal lawmakers tried to steer new physician training toward the specialties and places that need it most. Two laws authorized 1,000 new Medicare residency slots, allocated between 2023 and 2025, with rules favoring shortage areas, rural communities, and psychiatry. A new analysis finds the expansion grew the training pipeline but missed its primary care and rural targets. The result suggests that how slots are distributed, not just how many are created, determines whether shortages ease.

Physician shortages in primary care, psychiatry, and rural communities limit access and worsen outcomes. Congress built the two appropriations acts to address exactly those gaps, with explicit rules: all 2021 act slots to shortage areas, 10% to rural counties, and at least half of the 2023 act slots to psychiatry. With every round now allocated, this study assessed whether the laws hit their own marks.

The 2021 act reserved 10% of slots for rural counties, but rural placement started at 6% in round 1 and fell to 3% by round 4. The 2023 act sent just 1% of its positions to rural areas. Primary care followed a similar slide: its share dropped to 31.5% in round 4 from 53% in round 1, a 22-point decline. Psychiatry moved the other way, taking 54.5% of the 2023 act's slots. Shortage areas fared better. All 2021 act positions landed in designated shortage areas, though that share eased to 81.6% under the 2023 act.

This was a cross-sectional analysis of all 1,000 new positions allocated from 2023 to 2025, 800 from the 2021 act and 200 from the 2023 act. The team classified each by specialty and location and compared specialty growth against a 2021 match-data baseline.

Medicare's rural definition is broad, so residents at nonrural sites that serve rural populations may still gain rural exposure the slot counts miss. The study also could not track whether graduates ultimately practice primary care or stay in rural areas.

"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," said lead author Tarun Ramesh, MD, a research fellow at the Harvard Pilgrim Health Care Institute.

Source: Ramesh T, et al. JAMA. 2026 Jun 15. Changes in Specialty and Geography of Medicare's New Residency Positions