I 

118TH CONGRESS 

1ST SESSION H. R. 2389 

To amend title XVIII of the Social Security Act to provide for the distribution 

of additional residency positions, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 29, 2023 

Ms. SEWELL (for herself and Mr. FITZPATRICK) introduced the following bill; 

which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for the distribution of additional residency positions, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Resident Physician 

5 Shortage Reduction Act of 2023’’. 


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1 SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI2 TIONS. 

3 (a) IN GENERAL.—Section 1886(h) of the Social Se4 curity Act (42 U.S.C. 1395ww(h)) is amended— 

5 (1) in paragraph (4)(F)(i), by striking ‘‘para6 graphs (7), (8), (9), and (10)’’ and inserting ‘‘para7 graphs (7), (8), (9), (10), and (11)’’; 

8 (2) in paragraph (4)(H)(i), by striking ‘‘para9 graphs (7), (8), (9), and (10)’’ and inserting ‘‘para10 graphs (7), (8), (9), (10), and (11)’’; 

11 (3) in paragraph (7)(E), by inserting ‘‘para12 graph (10),’’ after ‘‘paragraph (8),’’; and 

13 (4) by adding at the end the following new 

14 paragraph: 

15 ‘‘(11) DISTRIBUTION OF ADDITIONAL RESI16 DENCY POSITIONS.— 

17 ‘‘(A) ADDITIONAL RESIDENCY POSI18 TIONS.— 

19 ‘‘(i) IN GENERAL.—For each of fiscal 

20 years 2025 through 2031 (and succeeding 

21 fiscal years if the Secretary determines 

22 that there are additional residency posi23 tions available to distribute under clause 

24 (iv)(II)), the Secretary shall, subject to 

25 clause (ii) and subparagraph (D), increase 

26 the otherwise applicable resident limit for 


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1 each qualifying hospital (as defined in sub2 paragraph (H)) that submits a timely ap3 plication under this subparagraph by such 

4 number as the Secretary may approve for 

5 portions of cost reporting periods occurring 

6 on or after July 1 of the fiscal year of the 

7 increase. 

8 ‘‘(ii) NUMBER AVAILABLE FOR DIS9 TRIBUTION.—For each such fiscal year, 

10 the Secretary shall determine the total 

11 number of additional residency positions 

12 available for distribution under clause (i) 

13 in accordance with the following: 

14 ‘‘(I) ALLOCATION TO HOSPITALS

15 ALREADY OPERATING OVER RESIDENT

16 LIMIT.—One-third of such number 

17 shall be available for distribution only 

18 to hospitals described in subparagraph 

19 (B). 

20 ‘‘(II) AGGREGATE LIMITATION.— 

21 Except as provided in clause (iv)(I), 

22 the aggregate number of increases in 

23 the otherwise applicable resident limit 

24 under this subparagraph shall be 

25 equal to 2,000 in each such year. 


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1 ‘‘(iii) PROCESS FOR DISTRIBUTING

2 POSITIONS.— 

3 ‘‘(I) ROUNDS OF APPLICA4 TIONS.—The Secretary shall initiate 7 

5 separate rounds of applications for an 

6 increase under clause (i), 1 round 

7 with respect to each of fiscal years 

8 2025 through 2031. 

9 ‘‘(II) NUMBER AVAILABLE.—In 

10 each of such rounds, the aggregate 

11 number of positions available for dis12 tribution in the fiscal year under 

13 clause (ii) shall be distributed, plus 

14 any additional positions available 

15 under clause (iv). 

16 ‘‘(III) TIMING.—The Secretary 

17 shall notify hospitals of the number of 

18 positions distributed to the hospital 

19 under this paragraph as a result of an 

20 increase in the otherwise applicable 

21 resident limit by January 1 of the fis22 cal year of the increase. Such increase 

23 shall be effective for portions of cost 

24 reporting periods beginning on or 

25 after July 1 of that fiscal year. 


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1 ‘‘(iv) POSITIONS NOT DISTRIBUTED

2 DURING THE FISCAL YEAR.— 

3 ‘‘(I) IN GENERAL.—If the num4 ber of resident full-time equivalent po5 sitions distributed under this para6 graph in a fiscal year is less than the 

7 aggregate number of positions avail8 able for distribution in the fiscal year 

9 (as described in clause (ii), including 

10 after application of this subclause), 

11 the difference between such number 

12 distributed and such number available 

13 for distribution shall be added to the 

14 aggregate number of positions avail15 able for distribution in the following 

16 fiscal year. 

17 ‘‘(II) EXCEPTION IF POSITIONS

18 NOT DISTRIBUTED BY END OF FISCAL

19 YEAR 2031.—If the aggregate number 

20 of positions distributed under this 

21 paragraph during the 7-year period of 

22 fiscal years 2025 through 2031 is less 

23 than 14,000, the Secretary shall, in 

24 accordance with the provisions of 

25 clause (ii) and subparagraph (E) and 


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1 the considerations and priority de2 scribed in subparagraph (C), conduct 

3 an application and distribution proc4 ess in each subsequent fiscal year 

5 until such time as the aggregate 

6 amount of positions distributed under 

7 this paragraph is equal to 14,000. 

8 ‘‘(B) ALLOCATION OF DISTRIBUTION FOR

9 POSITIONS TO HOSPITALS ALREADY OPERATING

10 OVER RESIDENT LIMIT.— 

11 ‘‘(i) IN GENERAL.—Subject to clauses 

12 (ii) and (iii), in the case of a hospital in 

13 which the reference resident level of the 

14 hospital (as specified in subparagraph 

15 (H)(ii)) is greater than the otherwise appli16 cable resident limit, the increase in the 

17 otherwise applicable resident limit under 

18 subparagraph (A) for a fiscal year de19 scribed in such subparagraph shall be an 

20 amount equal to the product of the total 

21 number of additional residency positions 

22 available for distribution under subpara23 graph (A)(ii)(I) for such fiscal year and 

24 the quotient of— 


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1 ‘‘(I) the number of resident posi2 tions by which the reference resident 

3 level of the hospital exceeds the other4 wise applicable resident limit for the 

5 hospital; and 

6 ‘‘(II) the number of resident po7 sitions by which the reference resident 

8 level of all such hospitals with respect 

9 to which an application is approved 

10 under this paragraph exceeds the oth11 erwise applicable resident limit for 

12 such hospitals. 

13 ‘‘(ii) REQUIREMENTS.—A hospital de14 scribed in clause (i)— 

15 ‘‘(I) is not eligible for an increase 

16 in the otherwise applicable resident 

17 limit under this subparagraph unless 

18 the amount by which the reference 

19 resident level of the hospital exceeds 

20 the otherwise applicable resident limit 

21 is not less than 10 and the hospital 

22 trains at least 25 percent of the full23 time equivalent residents of the hos24 pital in primary care and general surVerDate Sep 11 2014 22:30 Apr 08, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H2389.IH H2389

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1 gery (as of the date of enactment of 

2 this paragraph); and 

3 ‘‘(II) shall continue to train at 

4 least 25 percent of the full-time equiv5 alent residents of the hospital in pri6 mary care and general surgery for the 

7 5-year period beginning on such date. 

8 In the case where the Secretary determines 

9 that a hospital described in clause (i) no 

10 longer meets the requirement of subclause 

11 (II), the Secretary may reduce the other12 wise applicable resident limit of the hos13 pital by the amount by which such limit 

14 was increased under this subparagraph. 

15 ‘‘(iii) CLARIFICATION REGARDING ELI16 GIBILITY FOR OTHER ADDITIONAL RESI17 DENCY POSITIONS.—Nothing in this sub18 paragraph shall be construed as preventing 

19 a hospital described in clause (i) from ap20 plying for and receiving additional resi21 dency positions under this paragraph that 

22 are not reserved for distribution under this 

23 subparagraph. 

24 ‘‘(C) DISTRIBUTION OF OTHER POSI25 TIONS.—For purposes of determining an inVerDate Sep 11 2014 22:30 Apr 08, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H2389.IH H2389

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1 crease in the otherwise applicable resident limit 

2 under subparagraph (A) (other than such an in3 crease described in subparagraph (B)), the fol4 lowing shall apply: 

5 ‘‘(i) CONSIDERATIONS IN DISTRIBU6 TION.—In determining for which hospitals 

7 such an increase is provided under sub8 paragraph (A), the Secretary shall take 

9 into account the demonstrated likelihood of 

10 the hospital filling the positions made 

11 available under this paragraph within the 

12 first 5 cost reporting periods beginning 

13 after the date the increase would be effec14 tive, as determined by the Secretary. 

15 ‘‘(ii) MINIMUM DISTRIBUTION FOR

16 CERTAIN CATEGORIES OF HOSPITALS.— 

17 With respect to the aggregate number of 

18 such positions available for distribution 

19 under this paragraph, the Secretary shall 

20 distribute not less than 10 percent of such 

21 aggregate number to each of the following 

22 categories of hospitals: 

23 ‘‘(I) Hospitals that are located in 

24 a rural area (as defined in subsection 

25 (d)(2)(D)) or are treated as being loVerDate Sep 11 2014 22:30 Apr 08, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H2389.IH H2389

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1 cated in a rural area pursuant to sub2 section (d)(8)(E) or are located in 

3 Alaska, Hawaii, or a territory of the 

4 United States. 

5 ‘‘(II) Hospitals in which the ref6 erence resident level of the hospital 

7 (as specified in subparagraph (H)(ii)) 

8 is greater than the otherwise applica9 ble resident limit. 

10 ‘‘(III) Hospitals in States with— 

11 ‘‘(aa) new medical schools 

12 that received ‘Candidate School’ 

13 status from the Liaison Com14 mittee on Medical Education or 

15 that received ‘Pre-Accreditation’ 

16 status from the American Osteo17 pathic Association Commission 

18 on Osteopathic College Accredita19 tion on or after January 1, 2000, 

20 and that have achieved or con21 tinue to progress toward ‘Full 

22 Accreditation’ status (as such 

23 term is defined by the Liaison 

24 Committee on Medical Edu25 cation) or toward ‘Accreditation’ 


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1 status (as such term is defined 

2 by the American Osteopathic As3 sociation Commission on Osteo4 pathic College Accreditation); or 

5 ‘‘(bb) additional locations 

6 and branch campuses established 

7 on or after January 1, 2000, by 

8 medical schools with ‘Full Ac9 creditation’ status (as such term 

10 is defined by the Liaison Com11 mittee on Medical Education) or 

12 ‘Accreditation’ status (as such 

13 term is defined by the American 

14 Osteopathic Association Commis15 sion on Osteopathic College Ac16 creditation). 

17 ‘‘(IV) Hospitals that serve areas 

18 designated as health professional 

19 shortage areas under section 

20 332(a)(1)(A) of the Public Health 

21 Service Act, as determined by the Sec22 retary. 

23 ‘‘(iii) PRIORITIZATION IN DISTRIBU24 TION TO HPSA HOSPITALS.—In distrib25 uting positions to a hospital described in 


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1 clause (ii)(IV), the Secretary shall give pri2 ority to hospitals that are affiliated with— 

3 ‘‘(I) a historically Black medical 

4 school (as defined in subparagraph 

5 (H)); or 

6 ‘‘(II) any other school listed in 

7 section 326(e)(1) of the Higher Edu8 cation Act of 1965 that establishes a 

9 medical college. 

10 ‘‘(D) PROHIBITION ON DISTRIBUTION TO

11 HOSPITALS WITHOUT AN INCREASE AGREE12 MENT.—No increase in the otherwise applicable 

13 resident limit of a hospital may be made under 

14 subparagraph (C) unless such hospital agrees to 

15 increase the total number of full-time equivalent 

16 residency positions under the approved medical 

17 residency training program of such hospital by 

18 the number of such positions made available by 

19 such increase under the subparagraph. 

20 ‘‘(E) LIMITATION.— 

21 ‘‘(i) IN GENERAL.—Except as pro22 vided in clause (ii), a hospital may not re23 ceive more than 75 full-time equivalent ad24 ditional residency positions in the aggre25 gate under this paragraph, paragraph (9), 


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1 and paragraph (10) over the period of fis2 cal years 2025 through 2031. 

3 ‘‘(ii) INCREASE IN NUMBER OF ADDI4 TIONAL POSITIONS A HOSPITAL MAY RE5 CEIVE.—The Secretary shall increase the 

6 aggregate number of full-time equivalent 

7 additional residency positions a hospital 

8 may receive under this paragraph over 

9 such period if the Secretary estimates that 

10 the number of positions available for dis11 tribution under subparagraph (A) exceeds 

12 the number of applications approved under 

13 such subparagraph over such period. 

14 ‘‘(F) APPLICATION OF PER RESIDENT

15 AMOUNTS FOR PRIMARY CARE AND NONPRI16 MARY CARE.—With respect to additional resi17 dency positions in a hospital attributable to the 

18 increase provided under this paragraph, the ap19 proved FTE per resident amounts are deemed 

20 to be equal to the hospital per resident amounts 

21 for primary care and nonprimary care com22 puted under paragraph (2)(D) for that hospital. 

23 ‘‘(G) PERMITTING FACILITIES TO APPLY

24 AGGREGATION RULES.—The Secretary shall 

25 permit hospitals receiving additional residency 


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1 positions attributable to the increase provided 

2 under this paragraph to, beginning in the fifth 

3 year after the effective date of such increase, 

4 apply such positions to the limitation amount 

5 under paragraph (4)(F) that may be aggre6 gated pursuant to paragraph (4)(H) among 

7 members of the same affiliated group. 

8 ‘‘(H) DEFINITIONS.—In this paragraph: 

9 ‘‘(i) OTHERWISE APPLICABLE RESI10 DENT LIMIT.—The term ‘otherwise appli11 cable resident limit’ means, with respect to 

12 a hospital, the limit otherwise applicable 

13 under subparagraphs (F)(i) and (H) of 

14 paragraph (4) on the resident level for the 

15 hospital determined without regard to this 

16 paragraph but taking into account para17 graphs (7)(A), (7)(B), (8)(A), (8)(B), (9), 

18 (10)(A). and (10)(B). 

19 ‘‘(ii) REFERENCE RESIDENT LEVEL.— 

20 Except as otherwise provided in subclause 

21 (II), the term ‘reference resident level’ 

22 means, with respect to a hospital, the resi23 dent level for the most recent cost report24 ing period of the hospital ending on or be25 fore the date of enactment of this paraVerDate Sep 11 2014 22:30 Apr 08, 2023 Jkt 039200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\H2389.IH H2389

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1 graph, for which a cost report has been 

2 settled (or, if not, submitted (subject to 

3 audit)), as determined by the Secretary. 

4 ‘‘(iii) RESIDENT LEVEL.—The term 

5 ‘resident level’ has the meaning given such 

6 term in paragraph (7)(C)(i). 

7 ‘‘(iv) QUALIFYING HOSPITAL.—The 

8 term ‘qualifying hospital’ means a hospital 

9 described in subparagraph (B)(i) or any of 

10 subclauses (I) through (IV) of subpara11 graph (C)(ii). 

12 ‘‘(v) HISTORICALLY BLACK MEDICAL

13 SCHOOL.—The term ‘historically Black 

14 medical school’ means Howard University 

15 College of Medicine, Charles R. Drew Uni16 versity of Medicine and Science, Meharry 

17 Medical College, Morehouse School of Med18 icine, Xavier University Graduate School 

19 of Health Sciences and Medical School, 

20 and Maryland College of Osteopathic Medi21 cine at Morgan State University.’’. 

22 (b) IME.—Section 1886(d)(5)(B) of the Social Secu23 rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 

24 (1) in clause (v), in the third sentence, by strik25 ing ‘‘subsections (h)(7), (h)(8), (h)(9), and (h)(10)’’ 


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1 and inserting ‘‘subsections (h)(7), (h)(8), (h)(9), 

2 (h)(10), and (h)(11)’’; and 

3 (2) by adding after clause (xiii) the following 

4 new clause: 

5 ‘‘(xiv) For discharges occurring on or 

6 after July 1, 2026, insofar as an additional 

7 payment amount under this subparagraph 

8 is attributable to resident positions distrib9 uted to a hospital under subsection 

10 (h)(11), the indirect teaching adjustment 

11 factor shall be computed in the same man12 ner as provided under clause (ii) with re13 spect to such resident positions.’’. 

14 SEC. 3. STUDY AND REPORT ON STRATEGIES FOR INCREAS15 ING DIVERSITY. 

16 (a) STUDY.—The Comptroller General of the United 

17 States (in this section referred to as the ‘‘Comptroller 

18 General’’) shall conduct a study on strategies for increas19 ing the diversity of the health professional workforce. Such 

20 study shall include an analysis of strategies for increasing 

21 the number of health professionals from rural, lower in22 come, and underrepresented minority communities, includ23 ing which strategies are most effective for achieving such 

24 goal. 


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1 (b) REPORT.—Not later than 2 years after the date 

2 of enactment of this Act, the Comptroller General shall 

3 submit to Congress a report on the study conducted under 

4 subsection (a), together with recommendations for such 

5 legislation and administrative action as the Comptroller 

6 General determines appropriate. 

Æ 


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