I 
115TH CONGRESS 
1ST SESSION H. R. 2267 
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 
MAY 1, 2017 
Mr. CROWLEY (for himself and Mr. COSTELLO of Pennsylvania) 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 com-
mittee 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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Resident Physician 
Shortage Reduction Act of 2017’’. 
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SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI-
TIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Se-
curity Act (42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘para-
graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 
(8), and (9)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘para-
graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 
(8), and (9)’’; 
(3) in paragraph (7)(E), by inserting ‘‘para-
graph (9),’’ after ‘‘paragraph (8),’’; and 
(4) by adding at the end the following new 
paragraph: 
‘‘(9) DISTRIBUTION OF ADDITIONAL RESIDENCY 
POSITIONS.— 
‘‘(A) 
ADDITIONAL
RESIDENCY
POSI-
TIONS.— 
‘‘(i) IN GENERAL.—For each of fiscal 
years 2019 through 2023 (and succeeding 
fiscal years if the Secretary determines 
that there are additional residency posi-
tions available to distribute under clause 
(iv)(II)), the Secretary shall, subject to 
clause (ii) and subparagraph (D), increase 
the otherwise applicable resident limit for 
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each qualifying hospital that submits a 
timely application under this subparagraph 
by such number as the Secretary may ap-
prove for portions of cost reporting periods 
occurring on or after July 1 of the fiscal 
year of the increase. 
‘‘(ii) NUMBER
AVAILABLE
FOR
DIS-
TRIBUTION.—For each such fiscal year, 
the Secretary shall determine the total 
number of additional residency positions 
available for distribution under clause (i) 
in accordance with the following: 
‘‘(I) ALLOCATION TO HOSPITALS 
ALREADY OPERATING OVER RESIDENT 
LIMIT.—One-third of such number 
shall be available for distribution only 
to hospitals described in subparagraph 
(B). 
‘‘(II) AGGREGATE LIMITATION.— 
Except as provided in clause (iv)(I), 
the aggregate number of increases in 
the otherwise applicable resident limit 
under this subparagraph shall be 
equal to 3,000 in each such year. 
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the considerations and priority de-
scribed in subparagraph (C), conduct 
an application and distribution proc-
ess in each subsequent fiscal year 
until such time as the aggregate 
amount of positions distributed under 
this paragraph is equal to 15,000. 
‘‘(B) ALLOCATION OF DISTRIBUTION FOR 
POSITIONS TO HOSPITALS ALREADY OPERATING 
OVER RESIDENT LIMIT.— 
‘‘(i) IN GENERAL.—Subject to clauses 
(ii) and (iii), in the case of a hospital in 
which the reference resident level of the 
hospital (as specified in subparagraph 
(G)(iii)) is greater than the otherwise ap-
plicable resident limit, the increase in the 
otherwise applicable resident limit under 
subparagraph (A) for a fiscal year de-
scribed in such subparagraph shall be an 
amount equal to the product of the total 
number of additional residency positions 
available for distribution under subpara-
graph (A)(ii)(I) for such fiscal year and 
the quotient of— 
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‘‘(I) the number of resident posi-
tions by which the reference resident 
level of the hospital exceeds the other-
wise applicable resident limit for the 
hospital; and 
‘‘(II) the number of resident po-
sitions by which the reference resident 
level of all such hospitals with respect 
to which an application is approved 
under this paragraph exceeds the oth-
erwise applicable resident limit for 
such hospitals. 
‘‘(ii) REQUIREMENTS.—A hospital de-
scribed in clause (i)— 
‘‘(I) is not eligible for an increase 
in the otherwise applicable resident 
limit under this subparagraph unless 
the amount by which the reference 
resident level of the hospital exceeds 
the otherwise applicable resident limit 
is not less than 10 and the hospital 
trains at least 25 percent of the full- 
time equivalent residents of the hos-
pital in primary care and general sur-
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gery (as of the date of enactment of 
this paragraph); and 
‘‘(II) shall continue to train at 
least 25 percent of the full-time equiv-
alent residents of the hospital in pri-
mary care and general surgery for the 
5-year period beginning on such date. 
In the case where the Secretary determines 
that a hospital described in clause (i) no 
longer meets the requirement of subclause 
(II), the Secretary may reduce the other-
wise applicable resident limit of the hos-
pital by the amount by which such limit 
was increased under this subparagraph. 
‘‘(iii) CLARIFICATION REGARDING ELI-
GIBILITY
FOR
OTHER
ADDITIONAL
RESI-
DENCY POSITIONS.—Nothing in this sub-
paragraph shall be construed as preventing 
a hospital described in clause (i) from ap-
plying for and receiving additional resi-
dency positions under this paragraph that 
are not reserved for distribution under this 
subparagraph. 
‘‘(C) DISTRIBUTION
OF
OTHER
POSI-
TIONS.—For purposes of determining an in-
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crease in the otherwise applicable resident limit 
under subparagraph (A) (other than such an in-
crease described in subparagraph (B)), the fol-
lowing shall apply: 
‘‘(i) CONSIDERATIONS
IN
DISTRIBU-
TION.—In determining for which hospitals 
such an increase is provided under sub-
paragraph (A), the Secretary shall take 
into account the demonstrated likelihood of 
the hospital filling the positions made 
available under this paragraph within the 
first 5 cost reporting periods beginning 
after the date the increase would be effec-
tive, as determined by the Secretary. 
‘‘(ii) PRIORITY
FOR
CERTAIN
HOS-
PITALS.—Subject to clause (iii), in deter-
mining for which hospitals such an in-
crease is provided, the Secretary shall dis-
tribute the increase in the following pri-
ority order: 
‘‘(I) First, to hospitals in States 
with— 
‘‘(aa) new medical schools 
that received ‘Candidate School’ 
status from the Liaison Com-
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mittee on Medical Education or 
that received ‘Pre-Accreditation’ 
status from the American Osteo-
pathic Association Commission 
on Osteopathic College Accredita-
tion on or after January 1, 2000, 
and that have achieved or con-
tinue to progress toward ‘Full 
Accreditation’ status (as such 
term is defined by the Liaison 
Committee 
on 
Medical 
Edu-
cation) or toward ‘Accreditation’ 
status (as such term is defined 
by the American Osteopathic As-
sociation Commission on Osteo-
pathic College Accreditation); or 
‘‘(bb) 
additional 
locations 
and branch campuses established 
on or after January 1, 2000, by 
medical schools with ‘Full Ac-
creditation’ status (as such term 
is defined by the Liaison Com-
mittee on Medical Education) or 
‘Accreditation’ status (as such 
term is defined by the American 
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Osteopathic Association Commis-
sion on Osteopathic College Ac-
creditation). 
‘‘(II) Second, to hospitals with 
which the Secretary cooperates under 
section 7302(d) of title 38, United 
States Code. 
‘‘(III) Third, to hospitals that 
emphasize training in community- 
based settings or in hospital out-
patient departments. 
‘‘(IV) Fourth, to hospitals that 
are not located in a rural area and op-
erate an approved medical residency 
training program (or rural track) in a 
rural area or an approved medical 
residency training program with an 
integrated rural track. 
‘‘(V) Fifth, to all other hospitals. 
‘‘(iii) DISTRIBUTION TO HOSPITALS IN 
HIGHER PRIORITY GROUP PRIOR TO DIS-
TRIBUTION IN LOWER PRIORITY GROUPS.— 
The Secretary may only distribute such an 
increase to a lower priority group under 
clause (ii) if all qualifying hospitals in the 
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higher priority group or groups have re-
ceived the maximum number of increases 
under such subparagraph that the hospital 
is eligible for under this paragraph for the 
fiscal year. 
‘‘(iv) REQUIREMENTS FOR USE OF AD-
DITIONAL POSITIONS.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), a hospital that receives 
such an increase shall ensure, during 
the 5-year period beginning on the ef-
fective date of such increase, that— 
‘‘(aa) not less than 50 per-
cent of the positions attributable 
to such increase that are used in 
a given year during such 5-year 
period are used to train full-time 
equivalent residents in a shortage 
specialty residency program (as 
defined in subparagraph (G)(iv)), 
as determined by the Secretary 
at the end of such 5-year period; 
‘‘(bb) the total number of 
full-time equivalent residents, ex-
cluding any additional positions 
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attributable to such increase, is 
not less than the average number 
of full-time equivalent residents 
during the 3 most recent cost re-
porting periods ending on or be-
fore the effective date of such in-
crease; and 
‘‘(cc) the ratio of full-time 
equivalent residents in a shortage 
specialty residency program (as 
so defined) is not less than the 
average ratio of full-time equiva-
lent residents in such a program 
during the 3 most recent cost re-
porting periods ending on or be-
fore the effective date of such in-
crease. 
‘‘(II) REDISTRIBUTION OF POSI-
TIONS
IF
HOSPITAL
NO
LONGER 
MEETS
CERTAIN
REQUIREMENTS.— 
With respect to each fiscal year de-
scribed in subparagraph (A), the Sec-
retary shall determine whether or not 
a hospital described in subclause (I) 
meets the requirements of such sub-
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clause. In the case that the Secretary 
determines that such a hospital does 
not meet such requirements, the Sec-
retary shall— 
‘‘(aa) reduce the otherwise 
applicable resident limit of the 
hospital by the amount by which 
such limit was increased under 
this paragraph; and 
‘‘(bb) provide for the dis-
tribution of positions attributable 
to such reduction in accordance 
with the requirements of this 
paragraph. 
‘‘(D) LIMITATION.—A hospital may not re-
ceive more than 75 full-time equivalent addi-
tional residency positions under this paragraph 
for any fiscal year. 
‘‘(E) APPLICATION
OF
PER
RESIDENT 
AMOUNTS
FOR
PRIMARY
CARE
AND
NONPRI-
MARY CARE.—With respect to additional resi-
dency positions in a hospital attributable to the 
increase provided under this paragraph, the ap-
proved FTE per resident amounts are deemed 
to be equal to the hospital per resident amounts 
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for primary care and nonprimary care com-
puted under paragraph (2)(D) for that hospital. 
‘‘(F) PERMITTING
FACILITIES
TO
APPLY 
AGGREGATION
RULES.—The Secretary shall 
permit hospitals receiving additional residency 
positions attributable to the increase provided 
under this paragraph to, beginning in the fifth 
year after the effective date of such increase, 
apply such positions to the limitation amount 
under paragraph (4)(F) that may be aggre-
gated pursuant to paragraph (4)(H) among 
members of the same affiliated group. 
‘‘(G) DEFINITIONS.—In this paragraph: 
‘‘(i) OTHERWISE
APPLICABLE
RESI-
DENT LIMIT.—The term ‘otherwise appli-
cable resident limit’ means, with respect to 
a hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of 
paragraph (4) on the resident level for the 
hospital determined without regard to this 
paragraph but taking into account para-
graphs (7)(A), (7)(B), (8)(A), and (8)(B). 
‘‘(ii) REFERENCE RESIDENT LEVEL.— 
Except as otherwise provided in subclause 
(II), the term ‘reference resident level’ 
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means, with respect to a hospital, the resi-
dent level for the most recent cost report-
ing period of the hospital ending on or be-
fore the date of enactment of this para-
graph, for which a cost report has been 
settled (or, if not, submitted (subject to 
audit)), as determined by the Secretary. 
‘‘(iii) RESIDENT
LEVEL.—The term 
‘resident level’ has the meaning given such 
term in paragraph (7)(C)(i). 
‘‘(iv) SHORTAGE
SPECIALTY
RESI-
DENCY
PROGRAM.—The term ‘shortage 
specialty residency program’ means any 
approved residency training program in a 
specialty identified in the report entitled 
‘The Physician Workforce: Projections and 
Research into Current Issues Affecting 
Supply and Demand’, issued in December 
2008 by the Health Resources and Serv-
ices Administration, as a specialty whose 
baseline physician requirements projections 
exceed the projected supply of total active 
physicians for the period of 2005 through 
2020.’’. 
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(b) IME.—Section 1886(d)(5)(B) of the Social Secu-
rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 
(1) in clause (v), in the second sentence, by 
striking ‘‘subsections (h)(7) and (h)(8)’’ and insert-
ing ‘‘subsections (h)(7), (h)(8), and (h)(9)’’; 
(2) by redesignating clause (x), as added by 
section 5505(b) of the Patient Protection and Af-
fordable Care Act (Public Law 111–148), as clause 
(xi) and moving such clause 4 ems to the left; and 
(3) by adding after clause (xi), as redesignated 
by subparagraph (A), the following new clause: 
‘‘(xii) For discharges occurring on or 
after July 1, 2019, insofar as an additional 
payment amount under this subparagraph 
is attributable to resident positions distrib-
uted to a hospital under subsection (h)(9), 
the indirect teaching adjustment factor 
shall be computed in the same manner as 
provided under clause (ii) with respect to 
such resident positions.’’. 
SEC. 3. STUDY AND REPORT ON STRATEGIES FOR INCREAS-
ING DIVERSITY. 
(a) STUDY.—The Comptroller General of the United 
States (in this section referred to as the ‘‘Comptroller 
General’’) shall conduct a study on strategies for increas-
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