,,ii  #aac? ,,congress  #b;d ,session   
,s4 #aigh  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,janu>y #cj1 #bjad,mr4 
,udall ( ,new ,mexico introduc$ ! foll[+
 bill2 :i* 0 read twice & ref]r$ to !   
,committee on ,f9ance  ,a ,,bill  ,to   
increase access to prim>y c>e s]vices   
?r\gh tra9+ & acc\ntability improvem5ts4
  #a4 ,%ort title2 table ( cont5ts  7a7 
,%ort title ,?is ,act may be cit$ z !   
,increas+ ,prim>y ,c>e ,access ,act (   
#bjad4  7b7 ,table ( cont5ts ,! table ( 
cont5ts ( ?is ,act is z foll[s3 ,sec4   
#a4 ,%ort title2 table ( cont5ts4,sec4  
#b4 ,f9d+s4,sec4 #c4 ,c5t]s ( ,excell5ce
 9 ,prim>y ,c>e4,sec4 #d4 ,m$ic>e       
,indirect ,m$ical ,education 7,,ime7    
p]=mance adju/m5t & prim>y c>e tra9+    
bonus4,sec4 #e4 ,increas+ ,m$ic>e       
graduate m$ical education               
transp>5cy4,sec4 #f4 ,ensur+ appropriate
 repres5tation ( prim>y c>e physicians  
on gr\ps mak+ recomm5dations reg>d+     
relative values "u ! ,m$ic>e physician  
fee s*$ule4,sec4 #g4 ,prim>y c>e        

project4,sec4 #h4 ,regional c5t]s =     
heal? work=ce analysis4,sec4 #i4        
,paym5ts = graduate m$ical education "u 
! ,m$icaid program4,sec4 #aj4 ,national 
,c5t] = ,heal? ,c>e ,work=ce            
,analysis4,sec4 #aa4 ,tea*+ heal? c5t]  
reau?orization4,sec4 #ab4 ,,gao /udies  
on graduate m$ical education4  #b4      
,f9d+s ,congress makes ! foll[+ f9d+s3  
7#a7 ,a well prep>$1 effective prim>y   
c>e work=ce c r$uce heal? c>e co/s &    
play a l>ge role 9 ! prev5tion &        
managem5t ( illness4 ,a "o-unit increase
 9 prim>y c>e physicians p] #aj1jjj     
population is associat$ ) improv$ heal? 
outcomes su* z all-cause1 canc]1 he>t   
disease1 & /roke mortality1 z well z    
increas$ life expectancy4  7#b7 ,prim>y 
c>e physicians include ^? tra9$ 9 family
 m$ic9e1 g5]al int]nal m$ic9e1 g5]al    
p$iatrics1 & 9 "s cases1 gynecology4 ,"o
 prim>y c>e physician w g5]ate #f to #bc
 jobs 9 ! community s]v$ by su*         
physician1 #ijj1jjj to #a1bjj1jjj 9     
wages1 sal>ies1 & b5efits1 & ne>ly      

#ajj1jjj 9 ,/ate & local taxes4  7#c7 ,z
 ( #bjaa1 only #cb p]c5t ( ! physician  
work=ce is compris$ ( prim>y c>e & only 
betwe5 #af to #ah p]c5t ( graduates (   
allopa?ic m$ical s*ools are likely to   
pursue a c>e] 9 prim>y c>e4  7#d7       
,prim>y c>e supply has a positive effect
 on ! entire population1 b ! effect is  
great] 9 areas ) high] income inequality
 & pov]ty1 su* z rural areas4 ,only ab\t
 #aj p]c5t ( physicians 9 ,am]ica       
practice 9 rural areas :ile #bj p]c5t ( 
! ,unit$ ,/ates population is locat$ 9  
rural areas4  7#e7 ,geographic areas ) m
 g5]al & family physicians p] population
 h l[] rates ( mortality &              
hospitalization = conditions t %\ld be  
prev5table or detect$ e>ly1 su* z       
diabetes1 conge/ive he>t failure1 &     
hyp]t5sion4  7#f7 ,z ( ,may #bjaa1 !re 7
 #f1dai prim>y c>e heal? pr(essional    
%ortage areas1 compris$ ( #ff1cjj1jjj   
individuals4 ,x w\ld take #ag1fcf       
practition]s to meet su* individuals'   
ne$ = prim>y c>e provid]s4  #c4 ,c5t]s (

 ,excell5ce 9 ,prim>y ,c>e ,"p ,c (     
title ,,vii ( ! ,public ,heal? ,s]vice  
,act 7#db ,u4,s4,c4 #bick7 is am5d$ by  
add+ at ! end ! foll[+3  ,,iii ,c5t]s ( 
,excell5ce 9 ,prim>y ,c>e  #gdi;,c4     
,c5t]s ( ,excell5ce 9 ,prim>y ,c>e  7a7 
,9 g5]al ,! ,secret>y %all make grants  
to1 & ent] into contracts )1 s*ools (   
m$ic9e & o/eopa?ic m$ic9e = ! purpose ( 
assi/+ ! s*ools 9 support+ programs (   
excell5ce 9 prim>y c>e4  7b7 ,eligible  
s*ools ,to be eligible to receive a     
grant "u subsection 7a71 a s*ool (      
m$ic9e or o/eopa?ic m$ic9e %all submit  
an application at su* "t1 9 su* mann]1 &
 conta9+ su* in=mation z ! ,secret>y may
 require1 includ+ a description (       
innovative ideas t applicants propose to
 increase recruitm5t & ret5tion 9 prim>y
 c>e1 includ+ pipel9e1 admissions1      
curriculum1 m5tor+1 prep>ation =        
resid5cy1 & relat$ purposes4  7c7       
,selection ( recipi5ts  7#a7 ,9 g5]al ,!
 ,secret>y %all aw>d a grant "u ?is     
section to n less ?an #f & n m ?an #aj  

eligible s*ools ( m$ic9e & o/eopa?ic    
m$ic9e4 ,su* select$ s*ools %all be     
designat$ z ,c5t]s ( ,excell5ce 9       
,prim>y ,c>e4  7#b7 ,requirem5ts relat+ 
to rural & und]s]v$ areas ,( ! s*ools   
designat$ "u p>agraph 7#a7-- 7,a7 n less
 ?an #d & n m ?an #g %all be locat$ 9 a 
rural area2 &  7,b7 n less ?an #b & n m 
?an #c %all be locat$ 9 a m$ically      
und]s]v$ area4  7d7 ,use ( funds ,a     
s*ool ( m$ic9e or o/eopa?ic m$ic9e      
designat$ z a ,c5t] ( ,excell5ce "u ?is 
section %all1 9 us+ funds provid$ "u !  
grant1 give fund+ priority to-- 7#a7    
mak+ m$ical s*ool af=dable = ea* admitt$
 & graduat$ /ud5t1 includ+ ?r\gh        
significant tuition s*ol>%ips1 tuition  
remissions1 & /ip5ds1 especially =      
l[-income /ud5ts1 & o!r provisions1 su* 
z loan =giv5ess = graduates :o practice 
prim>y c>e = a specifi$ duration ( "t2  
7#b7 conduct+ admissions processes t    
favor /ud5ts :o w "w 9 rural & m$ically 
und]s]v$ areas1 & consid] factors su* z 
rural bir?1 m9ority /atus or upbr++1 &  

desire to s]ve rural & m$ically und]s]v$
 populations2  7#c7 develop+ curricula  
models & innovations t exp$ite m$ical   
s*ool tra9+1 build ne$$ skills = mod]n  
m$ical practice1 & enhance aff9ity (    
graduates = practice 9 rural & m$ically 
und]s]v$ areas 7:i* may include #c-ye>  
und]graduate m$ical education models1   
rural & inn] city rotations1 & m5tor+ ) 
rural physicians72  7#d7 rese>* :e!r    
/ud5ts complet+ a s]vice requirem5t 9 a 
rural or und]s]v$ area z "p ( ! crit]ia 
= graduation improves access to c>e 9   
su* area2  7#e7 implem5t track+ sy/ems  
t-- 7,a7 assess practice patt]ns (      
m$ical s*ool graduates & require annual 
reports on ?is in=mation = ! duration ( 
! grant program2 &  7,b7 track all loan 
repaym5t & s*ol>%ip disbursem5ts to     
assure t program goals are be+ met )    
reg>d to recipi5ts s]v+ 9 desir$        
locations ) expect$ populations ( ne$ = 
a m9imum requir$ am\nt ( "t2 &  7#f7    
hav+ int]pr(essional prim>y c>e heal?   
pr(essions community-bas$ s]vice le>n+  

models = prim>y c>e resid5ts1 & include 
cl]k%ips & cont9uity cl9ic exp]i5ces =  
m$ical1 nurse practition]1 & physician  
assi/ant /ud5ts int]e/$ 9 prim>y c>e4  4
  #d4 ,m$ic>e ,indirect ,m$ical         
,education 7,,ime7 p]=mance adju/m5t &  
prim>y c>e tra9+ bonus  7a7 ,9 g5]al    
,section #ahhf7;d77#e77;,b7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#e77;,b77 is am5d$-- 7#a7 by 
r$esignat+ ! clause 7x7 z add$ by       
section #eeje7;b7 ( ! ,pati5t           
,protection & ,af=dable ,c>e ,act z     
clause 7xi72 &  7#b7 by add+ at ! end ! 
foll[+ new clauses3  7xii7 ,adju/m5t =  
p]=mance  7,i7 ,9 g5]al ,! ,secret>y1 9 
consultation ) ! advisory body "u clause
 7xiii71 %all e/abli% & implem5t        
proc$ures "u :i* ! am\nt ( paym5ts t a  
hospital w\ld o!rwise receive = indirect
 m$ical education co/s "u ?is           
subp>agraph = dis*>ges occurr+ dur+ an  
applicable p]iod is adju/$ bas$ on !    
p]=mance ( ! hospital on measures       
specifi$ by ! ,secret>y4  7,,ii7        

,measures ,! measures specifi$ by !     
,secret>y "u ?is clause %all include    
measures on quality measurem5t &        
improvem5t1 evid5ce-bas$ m$ic9e1        
int]pr(essional teamwork1               
multidiscipl9>y teamwork1 c>e           
coord9ation1 & heal? in=mation          
te*nology4 ,su* measures %all include   
factors t promote tra9+ 9 prim>y c>e1   
su* z-- 7aa7 resid5t tra9+ 9 outpati5t &
 community sett+s1 includ+ ,f$]ally     
qualifi$ heal? c5t]s1 rural heal?       
cl9ics1 tea*+ heal? c5t]s1 rural m$ical 
practices1 facilities op]at$ by !       
,vet]ans ,adm9i/ration1 ,indian ,heal?  
,s]vice facilities1 includ+ prim>y c>e  
tra9+ sites t are c>ri$ out ?r\gh self  
det]m9ation contracts & are locat$ 9 a  
rural or prim>y c>e heal? pr(essional   
%ortage area2  7bb7 sal>y & loan        
conditions = prim>y c>e resid5ts2  7cc7 
! p]c5tage ( all graduates practic+     
prim>y c>e #e ye>s aft] graduation2     
7dd7 ! p]c5tage ( all graduates practic+
 prim>y c>e 9 heal? pr(essional %ortage 

areas #e ye>s aft] graduation2  7ee7 !  
p]c5tage ( all prim>y c>e graduates f   
und]repres5t$ m9ority gr\ps1 includ+    
,african-,am]icans1 ,hispanic-,am]icans1
 & ,native ,am]icans1 z well z o!r      
und]s]v$ populations2  7ff7 h[ !        
resid5cy is respond+ to ! work=ce ne$s  
id5tifi$ by ,/ate & regional c5t]s =    
work=ce analysis e/abli%$ "u ! ,national
 ,c5t] = ,heal? ,c>e ,work=ce ,analysis 
or ! ,national ,heal? ,c>e ,work=ce     
,commission2  7gg7 ! provision ( s]vice 
to all socioeconomic levels ( pati5ts1  
includ+ b n limit$ to ,m$icaid program  
populations2  7hh7 m5tor+ curriculum 9  
prim>y c>e2  7ii7 sy/ems-bas$ practice1 
includ+ tra9+ 9 new =ms ( deliv]y sy/em 
models1 su* z c>e coord9ation1          
acc\ntable c>e organizations1 &         
pati5t-c5t]$ m$ical homes2 &  7jj7 tra9+
 9 prev5tive c>e1 *ronic disease        
managem5t1 & population heal? & public  
heal?4  7,,iii7 ,initial measure        
developm5t timel9e  7aa7 ,propos$ set ( 
measures ,n lat] ?an ,janu>y #a1 #bjaf1 

! ,secret>y %all publi% 9 ! ,f$]al      
,regi/] a propos$ set ( measures = use  
"u ?is clause4 ,! ,secret>y %all provide
 = a p]iod ( public comm5t on su*       
measures4  7bb7 ,f9al set ( measures ,n 
lat] ?an ,june #cj1 #bjaf1 ! ,secret>y  
%all publi% 9 ! ,f$]al ,regi/] ! f9al   
set ( measures to be specifi$ by !      
,secret>y = use "u ?is clause4  7,,iv7  
,adju/m5t ,subject to subclause 7,v71 ! 
,secret>y %all det]m9e ! am\nt ( any    
adju/m5t "u ?is clause to paym5ts to a  
hospital "u ?is subp>agraph 9 an        
applicable p]iod4  7,v7 ,budget-neutral 
) respect to paym5ts t w\ld o!rwise be  
made ,9 mak+ adju/m5ts "u ?is clause1 ! 
,secret>y %all ensure t ! total am\nt ( 
paym5ts made to all hospitals "u ?is    
subp>agraph = an applicable p]iod is    
equal to ! total am\nt ( paym5ts t w\ld 
h be5 made to su* hospitals "u ?is      
subp>agraph 9 su* p]iod if ?is clause _h
 n be5 enact$4  7,,vi7 ,prim>y c>e def9$
 ,9 ?is clause1 ! t]m prim>y c>e means  
family m$ic9e1 g5]al int]nal m$ic9e1    

g5]al p$iatrics1 prev5tive m$ic9e1      
ob/etrics & gynecology1 psy*iatry1 & any
 o!r specialty :i* provides integrat$1  
accessible heal? c>e s]vices & is       
acc\ntable = address+ a l>ge majority ( 
heal? c>e ne$s1 develop+ a su/a9$       
p>tn]%ip ) pati5ts1 & practic+ 9 !      
context ( family & community4  7,,vii7  
,applicable p]iod def9$ ,9 ?is clause1 !
 t]m applicable p]iod means ! #ab-mon?  
p]iod beg9n+ on ,july #a ( ea* ye>      
7beg9n+ ) #bjae74  7xiii7 ,use (        
advisory body  7,i7 ,9 g5]al ,subject to
 subclause 7,,iii71 ! ,secret>y %all    
e/abli% an advisory gr\p to advise !    
,secret>y on ! application ( clause     
7xii71 includ+ ! developm5t ( ! measures
 to be us$1 h[ data on ! measures may be
 collect$1 :i* measures w be requir$ 9  
any giv5 report+ p]iod1 ! applicable    
?re%olds = ! measures1 & ! me*anisms to 
be us$ 9 ord] to det]m9e :e!r a hospital
 has met a ?re%old4  7,,ii7 ,make-up (  
gr\p ,! advisory gr\p e/abli%$ "u       
subclause 7,i7 %all include-- 7aa7      

repres5tatives ( accr$it+ & c]tify+     
organizations2  7bb7 repres5tatives (   
facilities t receive paym5ts "u ?is     
subp>agraph2  7cc7 repres5tatives (     
specialty bo>ds & prim>y c>e bo>ds2     
7dd7 repres5tatives ( high-p]=m+ heal?  
c>e sy/ems2  7ee7 exp]ts 9 family       
m$ic9e1 prim>y c>e1 & prev5tive m$ic9e2 
7ff7 repres5tatives ( public & private  
pur*as]s2  7gg7 repres5tatives ( consum]
 & pati5t organizations1 especially ^? f
 rural areas2 &  7hh7 o!r entities &    
individuals z det]m9$ by ! ,secret>y (  
,heal? & ,human ,s]vices4  7,,iii7 ,use 
( exi/+ entity ,if ! ,secret>y det]m9es 
t an exi/+ entity is compris$ ( !       
individuals describ$ 9 subclause 7,,ii7 
& t su* entity has ! exp]tise to advise 
! ,secret>y on ! matt]s describ$ 9      
subclause 7,i71 ! ,secret>y may ent]    
into an arrangem5t ) su* entity to      
advise ! ,secret>y on su* matt]s r ?an  
e/abli%+ a new advisory gr\p "u         
subclause 7,i74  4  7b7 ,,gao /udy &    
report  7#a7 ,/udy ,! ,comptroll] ,g5]al

 ( ! ,unit$ ,/ates %all conduct a /udy  
on ! application ( clause 7xii7 (       
section #ahhf7;d77#e77;,b7 ( ! ,social  
,security ,act1 z add$ by subsection    
7a71 includ+ an analysis ( any *anges 9 
work=ce patt]ns z a result ( !          
application ( su* clause4  7#b7 ,report 
,n lat] ?an ,janu>y #a1 #bjah1 !        
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all submit to ,congress a report on !  
/udy conduct$ "u p>agraph 7#a71 toge!r )
 recomm5dations = su* legislation &     
adm9i/rative action z ! ,comptroll]     
,g5]al det]m9es to be appropriate4  #e4 
,increas+ ,m$ic>e graduate m$ical       
education transp>5cy  7a7 ,9 g5]al ,n   
lat] ?an #b ye>s aft] ! date ( !        
enactm5t ( ?is ,act1 & annually !reaft]1
 ! ,secret>y ( ,heal? & ,human ,s]vices 
%all submit to ,congress a report on !  
graduate m$ical education paym5ts t     
hospitals & o!r facilities receive "u ! 
,m$ic>e program4 ,! report %all include 
! foll[+ in=mation ) respect to ea*     
hospital or facility t receives su*     

paym5ts3 7#a7 ,! direct graduate m$ical 
education paym5ts made to ! hospital or 
o!r facility "u section #ahhf7;h7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7h774  7#b7 ,! indirect m$ical   
education paym5ts made to ! hospital or 
o!r facility "u section                 
#ahhf7;d77#e77;,b7 ( su* ,act 7#db      
,u4,s4,c4 #acieww7d77#a77;,b774  7#c7 ,!
 numb] ( resid5ts c\nt$ = purposes (    
mak+ ! paym5ts describ$ 9 p>agraph 7#a74
  7#d7 ,! numb] ( resid5ts c\nt$ =      
purposes ( mak+ ! paym5ts describ$ 9    
p>agraph 7#b74  7#e7 ,! numb] (         
resid5ts1 if any1 t are n c\nt$ =       
purposes ( mak+ paym5ts describ$ 9      
p>agraph 7#a74  7#f7 ,! numb] (         
resid5ts1 if any1 t are n c\nt$ =       
purposes ( mak+ paym5ts describ$ 9      
p>agraph 7#b74  7#g7 ,! p]c5t t !       
paym5ts describ$ 9 p>agraphs 7#a7 & 7#b7
 t are made to ! hospital or o!r        
facility make up ( ! total co/s t !     
hospital or o!r facility incurs 9       
provid+ graduate m$ical education1      

includ+ sal>ies1 b5efits1 op]ational    
exp5ses1 & all o!r pati5t c>e co/s4     
7#h7 ,! numb] ( resid5ts tra9+ 9 ea*    
specialty4  7#i7 ,a li/ t id5tifies any 
tra9+ p>tn]s & ! sponsor+ in/itutions = 
ea* resid5cy program4  #f4 ,ensur+      
appropriate repres5tation ( prim>y c>e  
physicians on gr\ps mak+ recomm5dations 
reg>d+ relative values "u ! ,m$ic>e     
physician fee s*$ule ,section           
#ahdh7;c77#b77;,b77iii7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7;c77#b77;,b77iii77 is am5d$ by
 add+ at ! end ! foll[+ new s5t5ce3 ,!  
,secret>y may n consult ) an            
organization repres5t+ physicians if !  
organization uses a gr\p to =mulate     
recomm5dations reg>d+ adju/m5ts "u      
clause 7i7 unless at lea/ #dj p]c5t ( ! 
memb]s ( ! gr\p are physicians :o are   
bo>d c]tifi$ & actively practic+ 9      
family m$ic9e1 g5]al int]nal m$ic9e1    
g5]al p$iatrics1 prev5tive m$ic9e1      
ob/etrics & gynecology1 or psy*iatry44  
#g4 ,prim>y c>e project  7a7 ,9 g5]al ,!

 ,secret>y ( ,heal? & ,human ,s]vices   
7ref]r$ to 9 ?is section z ! ,secret>y7 
%all e/abli% a pilot program to provide 
fund+ = graduate m$ical resid5cy tra9+  
programs 9 prim>y c>e4  7b7 ,application
 & selection ( sites  7#a7 ,9 g5]al ,an 
entity %all be eligible to p>ticipate 9 
! project "u ?is section if su* entity--
 7,a7 is-- 7i7 a community-bas$         
corporate entity collaborat+ ) #a or m  
hospitals to op]ate a prim>y c>e        
resid5cy program2  7ii7 a m$ical        
education entity e/abli%$ by #a or m    
hospitals to op]ate a prim>y c>e        
resid5cy program2  7iii7 a hospital     
subsidi>y or indep5d5t corporation      
op]at+ a prim>y c>e resid5cy program2   
7iv7 a m$ical education entity1         
indep5d5t ( a hospital1 collaborat+ ) a 
prim>y c>e resid5cy program2 or  7v7    
ano!r type ( entity z det]m9$           
appropriate by ! ,secret>y2 &  7,b7     
submits an application at su* "t1 9 su* 
mann]1 & conta9+ su* in=mation z !      
,secret>y may require4  7#b7 ,selection 

( p>ticipants ,! ,secret>y %all select1 
f ! eligible entities "u p>agraph 7#a71 
#d entities to p>ticipate 9 ! project4  
,n less ?an #a select$ entity %all be an
 entity t is n a hospital4  7c7         
,activities "u ! project ,9 c>ry+ out ! 
project1 ! ,secret>y %all-- 7#a7        
/ructure ! fund+ ( ! project su* t      
paym5ts are made directly to ! entity   
p>ticipat+ 9 ! project2  7#b7 support   
prim>y c>e tra9+ 9 all sites :]e c>e is 
deliv]$1 includ+ non-hospital sett+s su*
 z ,f$]ally qualifi$ heal? c5t]s 7z     
def9$ 9 section #ahfa7;aa7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#aciex7aa7772  7#c7 7,a7 increase fund+ 
= ! prim>y c>e resid5cy programs ( !    
p>ticipat+ entities su* t ^? prim>y c>e 
resid5cy programs are fund$ at ! #ij?   
p]c5tile ( all resid5cy programs        
nationally & are fund$ at levels t equal
 at lea/ #ajj1jjj p] resid5t involv$2 & 
7,b7 ensure t entities p>ticipat+ 9 !   
project use ! fund+ "u ! project to     
provide infra/ructure support &         

recruitm5t & ret5tion support = faculty 
& resid5ts ( ! prim>y c>e resid5cy      
program1 includ+ loan repaym5t = su*    
resid5ts2  7#d7 require tra9+ 9 rural & 
m$ically und]s]v$ areas1 & ) m$ically   
und]s]v$ populations 7z def9$ 9 section 
#ccj7;b7 ( ! ,public ,heal? ,s]vice ,act
 7#db ,u4,s4,c4 #bed;b7b777 & s]vice 9  
su* areas = a m9imum ( two rotations ( n
 less ?an f\r weeks ea* ye>2 &  7#e7    
p]mit ! prim>y c>e resid5cy program ( ! 
p>ticipat+ entities to qualify = paym5t 
"u section #ahhf7;d77#e77;,b77xii7 ( !  
,social ,security ,act 7z add$ by       
section #d7 if su* entities receive an  
appropriate score 7z det]m9$ by !       
,secret>y7 on ! measures specifi$ by !  
,secret>y "u su* section4  7d7 ,t]m (   
project ,! ,secret>y %all c>ry out !    
project "u ?is section = a t]m ( at lea/
 #f ye>s4  7e7 ,evaluation  7#a7 ,9     
g5]al ,n lat] ?an #a ye> aft] !         
comm5cem5t ( ! project1 & ea* ye>       
!reaft]1 ! ,secret>y %all conduct an (  
evaluation ! project4  7#b7 ,cont5t ,!  

,secret>y %all conduct ! evaluation "u  
p>agraph 7#a7 us+ ! foll[+ crit]ia3 7,a7
 ,! p]c5tage ( graduates f ! prim>y c>e 
resid5cy programs ( ! p>ticipat+        
entities t are practic+ prim>y c>e #b   
ye>s aft] graduation1 & long]4  7,b7 ,! 
p]c5tage ( graduates f ! prim>y c>e     
resid5cy programs ( ! p>ticipat+        
entities t are practic+ 9 a heal?       
pr(essional %ortage area 7z def9$ 9     
section #ccb ( ! ,public ,heal? ,s]vice 
,act 7#db ,u4,s4,c4 #bed;e77 #b ye>s    
aft] graduation1 & long]4  7,c7 ,o!r    
crit]ia z det]m9$ appropriate by !      
,secret>y4  7f7 ,au?orization (         
appropriation ,!re are au?oriz$ to be   
appropriat$ to c>ry out ?is section     
#c1fjj1jjj = ea* ( fiscal ye>s #bjae    
?r\gh #bjai4  #h4 ,regional c5t]s =     
heal? work=ce analysis  7a7 ,9 g5]al    
,section #gfa7;c7 ( ! ,public ,heal?    
,s]vice ,act 7#db ,u4,s4,c4 #bidn7c77 is
 am5d$ by add+ at ! end ! foll[+--  7#c7
 ,e/abli%m5t ( new ,c5t]s & fund+ to    
prim>y c>e resid5cy programs  7,a7      

,e/abli%m5t ( new ,c5t]s  7i7 ,9 g5]al  
,n lat] ?an #a ye> aft] ! date (        
enactm5t ( ! ,increas+ ,prim>y ,c>e     
,access ,act ( #bjad1 ! ,secret>y %all  
aw>d grants to1 or ent] into contracts  
)1 n less ?an #f & n m ?an #h additional
 eligible entities1 z describ$ 9        
p>agraph 7#a74  7ii7 ,requirem5ts ,9    
aw>d+ grants or ent]+ into contracts "u 
clause 7i71 ! ,secret>y %all-- 7,i7     
ensure t ea* ,regional ,c5t] = ,heal?   
,work=ce ,analysis e/abli%$ "u ?is      
p>agraph is locat$ 9 ! geographic region
 t ! ,c5t] cov]s2 &  7,,ii7 seek to aw>d
 su* grants or ent] into contracts )    
eligible entities t are multi-,/ate     
consortia4  7,b7 ,di/ribution ( fund+ to
 prim>y c>e resid5cy programs  7i7 ,9   
g5]al ,ea* ,regional ,c5t] = ,heal?     
,work=ce ,analysis e/abli%$ pursuant to 
a grant or contract "u subp>agraph 7,a7 
%all1 f ! funds describ$ 9 subp>agraph  
7,d71 allocate fund+ to prim>y c>e      
resid5cy programs-- 7,i7 )9 ! region    
s]v$ by ! ,regional ,c5t] = ,heal?      

,work=ce ,analysis2 &  7,,ii7 t ! ,c5t] 
has id5tifi$ z a prim>y c>e resid5cy    
program 9 ne$4  7,c7 ,consultation ,ea* 
,regional ,c5t] = ,heal? ,work=ce       
,analysis e/abli%$ pursuant to a grant  
or contract "u ?is subsection %all      
e/abli% a consortium ( academic         
in/itutions ) :i* ! ,c5t] %all consult 9
 det]m9+ allocations "u subp>agraph     
7,b74  7,d7 ,fund+  7i7 ,au?orization ( 
appropriations ,= ea* fiscal ye>1 !re is
 au?oriz$ to be appropriat$ to c>ry out 
?is p>agraph #d1jjj1jjj1 ( :i* n less   
?an #ejj1jjj %all be allocat$ to ea*    
,regional ,c5t] = ,heal? ,work=ce       
,analysis e/abli%$ "u ?is p>agraph4     
7ii7 ,use ( funds to e/abli% new ,c5t]s 
,ea* entity receiv+ funds "u ?is        
p>agraph may use a portion ( su* fund+  
to e/abli% ! ,regional ,c5t] = ,heal?   
,work=ce ,analysis4  4  7b7 ,con=m+     
am5dm5t ,section #gfa7;e77#b7 ( !       
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #bidn7e77#b77 is am5d$ by     
/rik+ subsection 7c7 & ins]t+ p>agraphs 

7#a7 & 7#b7 ( subsection 7c74  #i4      
,paym5ts = graduate m$ical education "u 
! ,m$icaid program  7a7 ,9 g5]al        
,section #aije ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acif;d71 is am5d$  
by add+ at ! end ! foll[+ new           
subsection3  7ee7 ,increas$ ,,fmap =    
t>get$ graduate m$ical education 9      
,expansion ,/ates  7#a7 ,9 g5]al ,! t]m 
m$ical assi/ance includes paym5t = co/s 
( graduate m$ical education consi/5t )  
?is subsection1 :e!r provid$ 9 or       
outside ( a hospital4  7#b7 ,increas$   
,,fmap = ,expansion ,/ates t exp& t>get$
 graduate m$ical education ,not)/&+     
subsection 7b71 ) respect to am\nts     
exp5d$ by an ,expansion ,/ate = m$ical  
assi/ance = t>get$ graduate m$ical      
education t is above ! level (          
exp5ditures made by ! ,expansion ,/ate =
 su* graduate m$ical education = #bjad1 
! ,f$]al m$ical assi/ance p]c5tage %all 
be equal to-- 7,a7 #ajj p]c5t = am\nts  
exp5d$ 9 cal5d> qu>t]s 9 #bjae1 #bjaf1  
or #bjag2  7,b7 #ie p]c5t = am\nts      

exp5d$ 9 cal5d> qu>t]s 9 #bjah2  7,c7   
#id p]c5t = am\nts exp5d$ 9 cal5d>      
qu>t]s 9 #bjai2  7,d7 #ic p]c5t = am\nts
 exp5d$ 9 cal5d> qu>t]s 9 #bjbj2 &  7,e7
 #ij p]c5t = am\nts exp5d$ 9 cal5d>     
qu>t]s 9 #bjba or 9 ea* ye> !reaft]4    
7#c7 ,def9itions ,9 ?is subsection3 7,a7
 ,expansion ,/ate ,! t]m ,expansion     
,/ate means a ,/ate t elects 9          
accordance ) ! am5dm5ts made by !       
,pati5t ,protection & ,af=dable ,c>e    
,act 7,public ,law #aaa-adh7 to ?is     
title to provide m$ical assi/ance to    
individuals describ$ 9 subclause        
7,,viii7 ( section                      
#aijb7;a77#aj77;,a77i74  7,b7 ,t>get$   
graduate m$ical education ,! t]m t>get$ 
graduate m$ical education means graduate
 m$ical education = community-bas$1     
int]pr(essional prim>y c>e resid5ts &   
o!r heal? c>e /ud5ts1 locat$ 9 a rural  
area or an area t is designat$ 7"u      
section #ccb7;a77#a77;,a7 ( ! ,public   
,heal? ,s]vice ,act7 z a heal?          
pr(essional %ortage area1 or = o!r      

work=ce ne$s id5tifi$ by ,/ate &        
regional c5t]s = work=ce analysis       
e/abli%$ "u ! ,national ,c5t] = ,heal?  
,work=ce ,analysis4  7,c7 ,prim>y c>e ,!
 t]m prim>y c>e means family m$ic9e1    
g5]al int]nal m$ic9e1 g5]al p$iatrics1  
prev5tive m$ic9e1 ob/etrics &           
gynecology1 psy*iatry1 & any o!r        
specialty :i* provides integrat$1       
accessible heal? c>e s]vices & is       
acc\ntable = address+ a l>ge majority ( 
heal? c>e ne$s1 develop+ a su/a9$       
p>tn]%ip ) pati5ts1 & practic+ 9 !      
context ( family & community4  4  7b7   
,effective date ,! am5dm5ts made by ?is 
section %all take effect on ,janu>y #a1 
#bjae4 ,no?+ 9 ?is section %all be      
con/ru$ z affect+ paym5ts made be=e su* 
date "u a ,/ate plan "u title ,,xix ( ! 
,social ,security ,act = graduate m$ical
 education4  #aj4 ,national ,c5t] =     
,heal? ,c>e ,work=ce ,analysis ,section 
#gfa7;b77#b77;,a7 ( ! ,public ,heal?    
,s]vice ,act 7#db ,u4,s4,c4             
#bidn7b77#b77;,a77 is am5d$ by ins]t+   

be=e ! semicolon1 ! foll[+3 1 includ+   
national & regional work=ce issues      
relat$ to sp5d+ "u ! ,m$icaid program "u
 title ,,xix ( ! ,social ,security ,act4
  #aa4 ,tea*+ heal? c5t] reau?orization 
7a7 ,reau?orization ( ! tea*+ heal?     
c5t]s program ,section #cdj;,h ( !      
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #bef;h7 is am5d$-- 7#a7 9     
subsection 7g7-- 7,a7 by ins]t+ be=e !  
p]iod ! foll[+3 1 & n to exce$          
#hjj1jjj1jjj1 = ! p]iod ( fiscal ye>s   
#bjaf ?r\gh #bjbj2 &  7,b7 by add+ at ! 
end ! foll[+3 ,any am\nts appropriat$ "u
 ?is subsection = any ( fiscal ye>s     
#bjaa ?r\gh #bjbj & rema9+ unexp5d$ at !
 end ( ! fiscal ye> involv$ may be us$ 9
 subsequ5t fiscal ye>s to c>ry out ?is  
section42  7#b7 9 subsection 7h77#b7--  
7,a7 9 ! p>agraph head+1 by add+ at !   
end ! foll[+3 2 submission to ,congress2
 &  7,b7 by add+ at ! end ! foll[+3     
7,c7 ,submission to ,congress ,!        
,secret>y %all annually submit to       
,congress a report t conta9s a          

compilation ( ! data submitt$ to !      
,secret>y "u p>agraph 7#a7 = ! ye>      
involv$4  2  7#c7 by r$esignat+         
subsections 7h7 ?r\gh 7j7 z subsections 
7i7 ?r\gh 7k71 respectively2 &  7#d7 by 
ins]t+ aft] subsection 7g71 ! foll[+3   
7h7 ,limitation ,! ,secret>y %all       
e/abli% a m9imum p] resid5t p] ye>      
paym5t am\nt = fund+ ( all approv$ tea*+
 heal? c5t] graduate m$ical education   
positions "u ?is section t %all be n    
less ?an ! p] resid5t p] ye> paym5t     
am\nt z ( ,janu>y #a1 #bjac1 & ensure t 
n less ?an su* am\nt is provid$ to all  
tea*+ heal? c5t] graduate m$ical        
education programs = all approv$        
positions4  4  7b7 ,tea*+ heal? c5t]s   
developm5t grants ,section #gdi;,a7g7 ( 
! ,public ,heal? ,s]vice ,act 7#db      
,u4,s4,c4 #bicl-#a7;g77 is am5d$ by     
/rik+ ea* fiscal ye> !reaft] & ins]t+   
ea* ( fiscal ye>s #bjac ?r\gh #bjbj &   
ea* fiscal ye> !reaft]4  #ab4 ,,gao     
/udies on graduate m$ical education  7a7
 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ 

,/ates %all conduct a /udy on ea* ( !   
foll[+3 7#a7 ,! pot5tial ( mak+ graduate
 m$ical education paym5ts "u ! ,m$ic>e  
program = mid-level heal? provid]s 7su* 
z physician assi/ants & nurse           
practition]s7 9 ord] to all[ physicians 
& o!r heal? c>e provid]s to p]=m to _!  
full scope ( practice4  7#b7 ,! actual  
co/s involv$ 9 tra9+ resid5ts 9 diff]5t 
resid5cy specialty types4  7b7 ,report  
,n lat] ?an "o ye> aft] ! date ( !      
enactm5t ( ?is ,act1 ! ,comptroll]      
,g5]al ( ! ,unit$ ,/ates %all submit to 
,congress a report on ea* ( ! /udies    
conduct$ "u subsection 7a71 toge!r )    
recomm5dations = su* legislation &      
adm9i/rative action z ! ,comptroll]     
,g5]al det]m9es to be appropriate4