69–006 

110TH CONGRESS REPORT " ! HOUSE OF REPRESENTATIVES 2d Session 110–872 

PHYSICIAN WORKFORCE ENHANCEMENT ACT OF 2008 

SEPTEMBER 23, 2008.—Committed to the Committee of the Whole House on the 

State of the Union and ordered to be printed 

Mr. DINGELL, from the Committee on Energy and Commerce, 

submitted the following 

R E P O R T 

[To accompany H.R. 2583] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Energy and Commerce, to whom was referred 

the bill (H.R. 2583) to amend title VII of the Public Health Service 

Act to establish a loan program for eligible hospitals to establish 

residency training programs, having considered the same, report 

favorably thereon with an amendment and recommend that the bill 

as amended do pass. 

CONTENTS 

Page 

Amendment .............................................................................................................. 1 

Purpose and Summary ............................................................................................ 3 

Background and Need for Legislation .................................................................... 3 

Hearings ................................................................................................................... 4 

Committee Consideration ........................................................................................ 4 

Committee Votes ...................................................................................................... 4 

Committee Oversight Findings ............................................................................... 4 

Statement of General Performance Goals and Objectives .................................... 4 

New Budget Authority, Entitlement Authority, and Tax Expenditures ............. 4 

Earmarks and Tax and Tariff Benefits .................................................................. 5 

Committee Cost Estimate ....................................................................................... 5 

Congressional Budget Office Estimate ................................................................... 5 

Federal Mandates Statement ................................................................................. 6 

Advisory Committee Statement .............................................................................. 6 

Constitutional Authority Statement ...................................................................... 6 

Applicability to Legislative Branch ........................................................................ 7 

Section-by-Section Analysis of the Legislation ...................................................... 7 

Changes in Existing Law Made by the Bill, as Reported ..................................... 7 

AMENDMENT

The amendment is as follows: 


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Strike all after the enacting clause and insert the following: 

SECTION 1. SHORT TITLE. 

This Act may be cited as the ‘‘Physician Workforce Enhancement Act of 2008’’. 

SEC. 2. HOSPITAL RESIDENCY LOAN PROGRAM. 

Subpart 2 of part E of title VII of the Public Health Service Act is amended by 

adding at the end the following new section: 

‘‘SEC. 771. HOSPITAL RESIDENCY LOAN PROGRAM. 

‘‘(a) ESTABLISHMENT.—Not later than October 1, 2010, the Secretary, acting 

through the Administrator of the Health Resources and Services Administration, 

shall establish a hospital residency loan program that provides loans to eligible hospitals to establish a residency training program. 

‘‘(b) APPLICATION.—No loan may be provided under this section to an eligible hospital except pursuant to an application that is submitted and approved in a time, 

manner, and form specified by the Administrator of the Health Resources and Services Administration. A loan under this section shall be on such terms and conditions 

and meet such requirements as the Administrator determines appropriate, in accordance with the provisions of this section. 

‘‘(c) ELIGIBILITY; PREFERENCE FOR RURAL AREAS.— ‘‘(1) ELIGIBLE HOSPITAL DEFINED.—For purposes of this section, an ‘eligible 

hospital’ means, with respect to a loan under this section, a public or non-profit 

hospital that, as of the date of the submission of an application under subsection (b), meets, to the satisfaction of the Administrator of the Health Resources and Services Administration, each of the following criteria: 

‘‘(A) The hospital does not operate a residency training program and has 

not previously operated such a program. 

‘‘(B) The hospital has secured initial accreditation by the American Council for Graduate Medical Education or the American Osteopathic Association. 

‘‘(C) The hospital provides assurances to the satisfaction of the Administrator of the Health Resources and Services Administration that such loan 

shall be used, consistent with subsection (d), only for the purposes of establishing and conducting an allopathic or osteopathic physician residency 

training program in at least one of the following, or a combination of the 

following: 

‘‘(i) Family medicine. 

‘‘(ii) Internal medicine. 

‘‘(iii) Obstetrics or gynecology. 

‘‘(iv) Behavioral or Mental health. 

‘‘(v) Pediatrics. 

‘‘(D) The hospital enters into an agreement with the Administrator that 

certifies the hospital will provide for the repayment of the loan in accordance with subsection (e). 

‘‘(2) PREFERENCE FOR RURAL AREAS.—In making loans under this section, the 

Administrator of the Health Resources and Services Administration shall create 

guidelines that give preference to rural areas (as such term is defined in section 

1886(d)(2)(D) of the Social Security Act). 

‘‘(d) PERMISSIBLE USES OF LOAN FUNDS.—A loan provided under this section shall 

be used, with respect to a residency training program, only for costs directly attributable to the residency training program, except as otherwise provided by the Administrator of the Health Resources and Services Administration. 

‘‘(e) REPAYMENT OF LOANS.— 

‘‘(1) REPAYMENT PLANS.—For purposes of subsection (c)(1)(D), a repayment 

plan for an eligible hospital is in accordance with this subsection if it provides 

for the repayment of the loan amount in installments, in accordance with a 

schedule that is agreed to by the Administrator of the Health Resources and 

Services Administration and the hospital and that is in accordance with paragraphs (2), (3), and (4). 

‘‘(2) COMMENCEMENT OF REPAYMENT.—Repayment by an eligible hospital of a 

loan under this section shall commence not later than the date that is 18 

months after the date on which the loan amount is disbursed to such hospital. 

‘‘(3) REPAYMENT PERIOD.—A loan made under this section shall be fully repaid 

not later than the date that is 24 months after the date on which the repayment 

is required to commence. 

‘‘(4) LOAN PAYABLE IN FULL IF RESIDENCY TRAINING PROGRAM CANCELED.—In 

the case that an eligible hospital borrows a loan under this section, with respect 

to a residency training program, and terminates such program before the date 

on which such loan has been fully repaid in accordance with a plan under paraVerDate Aug 31 2005 15:06 Sep 28, 2008 Jkt 069006 PO 00000 Frm 00002 Fmt 6659 Sfmt 6621 E:\HR\OC\HR872.XXX HR872

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graph (1), such loan shall be payable by the hospital not later than 45 days 

after the date of such termination. 

‘‘(f) NO INTEREST CHARGED.—The Administrator of the Health Resources and 

Services Administration may not charge or collect interest on any loan made under 

this section. 

‘‘(g) LIMITATION ON TOTAL AMOUNT OF LOAN.—The cumulative annual dollar 

amount of a loan made to an eligible hospital under this section may not exceed 

$250,000. 

‘‘(h) PENALTIES.—The Administrator of the Health Resources and Services Administration shall establish penalties to which an eligible hospital receiving a loan 

under this section would be subject if such hospital is in violation of any of the criteria described in subsection (c)(1). Such penalties shall include the charge or collection of interest, at a rate to be determined by the Administrator of the Health Resources and Services Administration. Except as otherwise provided, penalties collected under this subsection shall be paid to the Administrator of the Health Resources and Services Administration and shall, subject to appropriation Acts, be 

available until expended for the purpose of enforcing the provisions of this section. 

‘‘(i) REPORTS.—Not later than January 1, 2012, and annually thereafter (before 

January 2, 2014), the Administrator of the Health Resources and Services Administration shall submit to Congress a report on the efficacy of the program under this 

section in increasing the number of residents practicing in each medical specialty 

described in subsection (c)(1)(C) during such year and the extent to which the program resulted in an increase in the number of available practitioners in each of 

such medical specialties that serve medically underserved populations. 

‘‘(j) FUNDING.— ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of providing 

amounts for loans under this section, there are authorized to be appropriated 

such sums as may be necessary to provide— ‘‘(A) $8,000,000 in loans for fiscal year 2010; 

‘‘(B) $8,400,000 in loans for fiscal year 2011; 

‘‘(C) $8,820,000 in loans for fiscal year 2012; 

‘‘(D) $9,261,000 in loans for fiscal year 2013; and 

‘‘(E) $9,724,050 in loans for fiscal year 2014. 

‘‘(2) AVAILABILITY.—Amounts appropriated under paragraph (1) shall remain 

available until expended. 

‘‘(k) TERMINATION OF PROGRAM.—No loan may be made under this section after 

December 31, 2013.’’. 

PURPOSE AND SUMMARY

The purpose of H.R. 2583, the Physician Workforce Enhancement 

Act of 2008, is to establish a loan program for eligible hospitals to 

establish residency training programs in allopathic and osteopathic 

medicine, with a preference for hospitals located in rural areas. 

BACKGROUND AND NEED FOR LEGISLATION

Recent trends in the physician workforce demonstrate that the 

growth in the physician workforce is not keeping pace with general 

population growth. Certain areas of practice, including primary 

care and pediatrics, are expected to have more critical shortages in 

the future. In 2006, the American College of Physicians released a 

report entitled ‘‘The Impending Collapse of Primary Care Medicine 

and Its Implications for the State of the Nation’s Health Care.’’ According to that report, as the demand has grown for primary care 

due to growth in the number of people with chronic diseases and 

long-term care needs of an aging population, there has been a decline in the number of medical students and training opportunities 

for primary care. This problem will only be further exacerbated by 

the decline of the physician workforce in years to come. 

Residency training programs are an integral way to attract physicians, particularly in hard-to-serve areas such as rural areas. In 

the 16th report of the Council of Graduate Medical Education, entitled, ‘‘Physician Workforce Policy Guidelines for the United States, 


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2000–2020,’’ the Council recommended that the number of physicians entering residency training each year should be increased to 

27,000 by 2015 to meet projected demand of medical services. The 

Council recommends a multifaceted approach to achieve this increase, and one important part of that plan is to facilitate a modest 

increase in medical education and training capacity over the next 

decade. 

One important source of funding for residency training programs 

is Medicare. The Medicare program, however, caps the number of 

residents and fellows eligible for Medicare reimbursement. This can 

narrow the number of resources available to some smaller hospitals 

that have the need for residents that will later serve the community as physicians. That cap was implemented at a time when it 

appeared that the physician workforce would enjoy surpluses for 

some time and that the use of managed health care services would 

reduce the demand for medical services. Both trends have significantly reversed in recent years, precipitating the need for a new 

strategy to improve the health and vitality of the U.S. physician 

workforce. 

HEARINGS

No hearings were held in connection with H.R. 2583. 

COMMITTEE CONSIDERATION

On Wednesday, September 17, 2008, the full Committee met in 

open markup session and ordered H.R. 2583 favorably reported to 

the House, amended, by a voice vote. 

COMMITTEE VOTES

Clause 3(b) of rule XIII of the Rules of the House of Representatives requires the Committee to list the record votes on the motion 

to report legislation and amendments thereto. No record votes were 

taken on amendments or in connection with ordering H.R. 2583 reported to the House. A motion by Mr. Dingell to order H.R. 2583 

favorably reported to the House, amended, was agreed to by a voice 

vote. 

COMMITTEE OVERSIGHT FINDINGS

Regarding clause 3(c)(1) of rule XIII of the Rules of the House 

of Representatives, the oversight findings of the Committee regarding H.R. 2583 are reflected in this report. 

STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

The objective of H.R. 2583 is to expand and improve the distribution of the physician workforce by creating new opportunities for 

residency training programs, particularly in rural areas. 

NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX

EXPENDITURES

Regarding compliance with clause 3(c)(2) of rule XIII of the Rules 

of the House of Representatives, the Committee finds that H.R. 

2583 would result in no new or increased budget authority, entitlement authority, or tax expenditures or revenues. 


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EARMARKS AND TAX AND TARIFF BENEFITS

Regarding compliance with clause 9 of rule XXI of the Rules of 

the House of Representatives, H.R. 2583 does not contain any congressional earmarks, limited tax benefits, or limited tariff benefits 

as defined in clause 9(d), 9(e), or 9(f) of rule XXI. 

COMMITTEE COST ESTIMATE

The Committee adopts as its own the cost estimate on H.R. 2583 

prepared by the Director of the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974. 

CONGRESSIONAL BUDGET OFFICE ESTIMATE

Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House 

of Representatives, the following is the cost estimate on H.R. 2583 

provided by the Congressional Budget Office pursuant to section 

402 of the Congressional Budget Act of 1974: 

U.S. CONGRESS, 

CONGRESSIONAL BUDGET OFFICE, 

Washington, DC, September 23, 2008. 

Hon. JOHN D. DINGELL, 

Chairman, Committee on Energy and Commerce, 

House of Representatives, Washington, DC. 

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 2583, the Physician 

Workforce Enhancement Act of 2008. 

If you wish further details on this estimate, we will be pleased 

to provide them. The CBO staff contact is Kirstin Nelson. 

Sincerely, 

PETER A. FONTAINE

(For Peter R. Orszag, Director). 

Enclosure. 

H.R. 2583—Physician Workforce Enhancement Act of 2008 

H.R. 2583, the Physician Workforce Enhancement Act of 2008, 

would allow eligible hospitals to receive a no-interest loan to establish a residency training program. Eligible hospitals are public or 

nonprofit hospitals that are not currently operating and have not 

previously operated a residency training program. Loans to individual hospitals could not exceed $250,000 annually. Loans could 

only be for costs directly related to certain residency programs in 

one of (or a combination of) the following areas: family medicine, 

internal medicine, obstetrics and gynecology, behavioral or mental 

health, and pediatrics. 

Assuming appropriation of the necessary amounts, CBO estimates that implementing the bill would cost an additional $1 million in 2010 and $4 million over the 2010–2013 period. Enacting 

H.R. 2583 would not affect direct spending or revenues. 

H.R. 2583 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act. Public 

hospitals in rural areas that establish residency training programs 

would benefit from loans authorized in the bill. 


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Under H.R. 2583, hospitals would be required to enter into an 

agreement with the Administrator of the Health Resources and 

Services Administration (HRSA) to repay the loan in installments 

beginning 18 months after the loan is disbursed. H.R. 2583 would 

require that loans be repaid no later than 24 months after the loan 

repayment begins. Under the bill, if a hospital receives a loan and 

then terminates the residency training program before repaying 

the loan, the hospital would have 45 days to repay the loan after 

terminating the residency program. In making loans to eligible hospitals, the HRSA Administrator would be required to establish 

guidelines that give preference to hospitals in rural areas. 

Lastly, H.R. 2583 would establish the loan program no later than 

October 1, 2010. No loans could be made under this program after 

December 31, 2013. 

H.R. 2583 would authorize the appropriation of such sums as 

may be necessary to provide $8 million in loans for 2010 and $34 

million in loans over the 2009–2013 period. Under the Federal 

Credit Reform Act of 1990, the cost of a loan program is measured 

as the net present value of cash flows over the life of the loan. Hospitals would begin to repay the loan 18 months after disbursement 

and would repay the entire loan amount within 24 months after repayments begin. CBO estimates that the subsidy cost for the nointerest loans would total about $1 million per year over the 2010– 

2013 period. 

The estimated cost of H.R. 2583 is shown in the following table. 

The costs of this legislation fall within budget function 550 

(health). 

By fiscal year, in millions of dollars— 

2009 2010 2011 2012 2013 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

Authorization Level .................................................................................................. 0 1 1 1 1 

Estimated Outlays ................................................................................................... 0 1 1 1 1 

The CBO staff contact for this estimate is Kirstin Nelson. This 

estimate was approved by Keith J. Fontenot, Deputy Assistant Director for Health and Human Resources, Budget Analysis Division. 

FEDERAL MANDATES STATEMENT

The Committee adopts as its own the estimate of Federal mandates regarding H.R. 2583 prepared by the Director of the Congressional Budget Office pursuant to section 423 of the Unfunded Mandates Reform Act. 

ADVISORY COMMITTEE STATEMENT

No advisory committees within the meaning of section 5(b) of the 

Federal Advisory Committee Act would be created by H.R. 2583. 

CONSTITUTIONAL AUTHORITY STATEMENT

Pursuant to clause 3(d)(1) of rule XIII of the Rules of the House 

of Representatives, the Committee finds that the Constitutional authority for H.R. 2583 is provided in the provisions of Article I, section 8, clause 1, that relate to expending funds to provide for the 

general welfare of the United States. 


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APPLICABILITY TO LEGISLATIVE BRANCH

The Committee finds that H.R. 2583 does not relate to the terms 

and conditions of employment or access to public services or accommodations within the meaning of section 102(b)(3) of the Congressional Accountability Act of 1995. 

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Short title 

Section 1 establishes the short title as the Physician Workforce 

Enhancement Act of 2008. 

Section 2. Hospital residency loan program 

Section 2 establishes the date of establishment for the program 

as October 1, 2010; clarifies that an eligible hospital means a public or non-profit hospital; establishes the list of eligible professions 

as family medicine, internal medicine, obstetrics or gynecology, behavioral or mental health, pediatrics, or a combination of such professions; extends the preference for loans to be given to rural areas, 

as defined by section 1886(d)(2)(D) of the Social Security Act; 

makes clear that permissible uses of loan funds are only meant to 

cover direct costs that are determined by the Administrator of the 

Health Resources and Services Administration to be necessary to 

run the residency training program; establishes the date to commence repayment as 18 months and the repayment period as 24 

months; sets the limitation on the total amount of the loan, so that 

no annual dollar amount may exceed $250,000; establishes a penalties provision so that the Secretary may collect interest, together 

with any other penalties, on defaulted loans (thereby making the 

restriction in subsection (f) subject to the authority to collect interest); and establishes the authorization of appropriations ($8 million 

for fiscal year (FY) 2009, $8.4 million for FY 2010, $8.82 million 

for FY 2011, $9.261 million for FY 2012; and $9,724,050 for FY 

2013); and terminates the program after December 31, 2013. 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, 

existing law in which no change is proposed is shown in roman): 

PUBLIC HEALTH SERVICE ACT 

* * * * * * * 

TITLE VII—HEALTH PROFESSIONS 

EDUCATION 

* * * * * * * 


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PART E—HEALTH PROFESSIONS AND PUBLIC 

HEALTH WORKFORCE 

* * * * * * * 

Subpart 2—Public Health Workforce 

* * * * * * * 

SEC. 771. HOSPITAL RESIDENCY LOAN PROGRAM. 

(a) ESTABLISHMENT.—Not later than October 1, 2010, the Secretary, acting through the Administrator of the Health Resources 

and Services Administration, shall establish a hospital residency 

loan program that provides loans to eligible hospitals to establish 

a residency training program. 

(b) APPLICATION.—No loan may be provided under this section to 

an eligible hospital except pursuant to an application that is submitted and approved in a time, manner, and form specified by the 

Administrator of the Health Resources and Services Administration. 

A loan under this section shall be on such terms and conditions and 

meet such requirements as the Administrator determines appropriate, in accordance with the provisions of this section. 

(c) ELIGIBILITY; PREFERENCE FOR RURAL AREAS.— 

(1) ELIGIBLE HOSPITAL DEFINED.—For purposes of this section, an ‘‘eligible hospital’’ means, with respect to a loan under 

this section, a public or non-profit hospital that, as of the date 

of the submission of an application under subsection (b), meets, 

to the satisfaction of the Administrator of the Health Resources 

and Services Administration, each of the following criteria: 

(A) The hospital does not operate a residency training 

program and has not previously operated such a program. 

(B) The hospital has secured initial accreditation by the 

American Council for Graduate Medical Education or the 

American Osteopathic Association. 

(C) The hospital provides assurances to the satisfaction of 

the Administrator of the Health Resources and Services Administration that such loan shall be used, consistent with 

subsection (d), only for the purposes of establishing and 

conducting an allopathic or osteopathic physician residency 

training program in at least one of the following, or a combination of the following: 

(i) Family medicine. 

(ii) Internal medicine. 

(iii) Obstetrics or gynecology. 

(iv) Behavioral or Mental health. 

(v) Pediatrics. 

(D) The hospital enters into an agreement with the Administrator that certifies the hospital will provide for the 

repayment of the loan in accordance with subsection (e). 

(2) PREFERENCE FOR RURAL AREAS.—In making loans under 

this section, the Administrator of the Health Resources and 

Services Administration shall create guidelines that give preference to rural areas (as such term is defined in section 

1886(d)(2)(D) of the Social Security Act). 


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(d) PERMISSIBLE USES OF LOAN FUNDS.—A loan provided under 

this section shall be used, with respect to a residency training program, only for costs directly attributable to the residency training 

program, except as otherwise provided by the Administrator of the 

Health Resources and Services Administration. 

(e) REPAYMENT OF LOANS.— 

(1) REPAYMENT PLANS.—For purposes of subsection (c)(1)(D), 

a repayment plan for an eligible hospital is in accordance with 

this subsection if it provides for the repayment of the loan 

amount in installments, in accordance with a schedule that is 

agreed to by the Administrator of the Health Resources and 

Services Administration and the hospital and that is in accordance with paragraphs (2), (3), and (4). 

(2) COMMENCEMENT OF REPAYMENT.—Repayment by an eligible hospital of a loan under this section shall commence not 

later than the date that is 18 months after the date on which 

the loan amount is disbursed to such hospital. 

(3) REPAYMENT PERIOD.—A loan made under this section 

shall be fully repaid not later than the date that is 24 months 

after the date on which the repayment is required to commence. 

(4) LOAN PAYABLE IN FULL IF RESIDENCY TRAINING PROGRAM

CANCELED.—In the case that an eligible hospital borrows a loan 

under this section, with respect to a residency training program, 

and terminates such program before the date on which such 

loan has been fully repaid in accordance with a plan under 

paragraph (1), such loan shall be payable by the hospital not 

later than 45 days after the date of such termination. 

(f) NO INTEREST CHARGED.—The Administrator of the Health Resources and Services Administration may not charge or collect interest on any loan made under this section. 

(g) LIMITATION ON TOTAL AMOUNT OF LOAN.—The cumulative annual dollar amount of a loan made to an eligible hospital under 

this section may not exceed $250,000. 

(h) PENALTIES.—The Administrator of the Health Resources and 

Services Administration shall establish penalties to which an eligible hospital receiving a loan under this section would be subject if 

such hospital is in violation of any of the criteria described in subsection (c)(1). Such penalties shall include the charge or collection 

of interest, at a rate to be determined by the Administrator of the 

Health Resources and Services Administration. Except as otherwise 

provided, penalties collected under this subsection shall be paid to 

the Administrator of the Health Resources and Services Administration and shall, subject to appropriation Acts, be available until expended for the purpose of enforcing the provisions of this section. 

(i) REPORTS.—Not later than January 1, 2012, and annually 

thereafter (before January 2, 2014), the Administrator of the Health 

Resources and Services Administration shall submit to Congress a 

report on the efficacy of the program under this section in increasing the number of residents practicing in each medical specialty described in subsection (c)(1)(C) during such year and the extent to 

which the program resulted in an increase in the number of available practitioners in each of such medical specialties that serve 

medically underserved populations. 

(j) FUNDING.— 


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(1) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 

providing amounts for loans under this section, there are authorized to be appropriated such sums as may be necessary to 

provide— (A) $8,000,000 in loans for fiscal year 2010; 

(B) $8,400,000 in loans for fiscal year 2011; 

(C) $8,820,000 in loans for fiscal year 2012; 

(D) $9,261,000 in loans for fiscal year 2013; and 

(E) $9,724,050 in loans for fiscal year 2014. 

(2) AVAILABILITY.—Amounts appropriated under paragraph 

(1) shall remain available until expended. 

(k) TERMINATION OF PROGRAM.—No loan may be made under this 

section after December 31, 2013. 

* * * * * * * 

Æ 


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