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  • Washington Highlights

    House Includes Historic Increase in GME Slots in Updated Build Back Better Act


    Allyson Perleoni, Director, Government Relations
    Christa Wagner, Manager, Government Relations
    Brett Roude, Legislative Analyst

    The House Committee on Rules passed a manager’s amendment to the Build Back Better Act (BBBA, H.R. 5376) on Nov. 4 that reflects a number of changes to the version released one week earlier [refer to Washington Highlights, Oct. 29]. While the $1.75 trillion package is still subject to change, the updated measure includes a number of provisions that affect academic medicine.

    The manager’s amendment included a new provision that would provide 4,000 new, Medicare-supported graduate medical education (GME) slots in 2025 and 2026. The legislation would require that 25% of the new slots go to primary care specialties and 15% of the slots to psychiatry and other behavioral health training programs. The slots would be distributed to eligible hospitals with 30% to teaching hospitals over their Medicare caps, 20% to teaching hospitals in rural areas, 20% to teaching hospitals in states with new medical schools or branch campuses, 20% to teaching hospitals located in or serving a health professional shortage area (HPSA), and 10% to teaching hospitals in states in the lowest quartile of resident-to-population ratio.

    The legislation would also provide annually up to approximately 1,000 cap-exempt Medicare-supported GME positions for the  Pathways to Practice Training Program to teaching hospitals that have achieved recognition by the Accreditation Council for Graduate Medical Education for providing mentorships, incorporating cultural competency in training, and having a record of training residents in underserved communities. The program would cover tuition, fees, and a monthly stipend for medical school or post-baccalaureate programs for student from disadvantaged backgrounds.

    The legislation continues to include a provision which would reduce Medicaid Disproportionate Share Hospital (DSH) allotments for non-expansion states by 12.5%, as low-income individuals falling into the Medicaid coverage gap would have access to Marketplace coverage. The Medicaid DSH reductions would be restored if a state later adopts Medicaid expansion.

    Additionally, the bill would limit Section 1115 demonstration uncompensated care pools for states that have not adopted Medicaid expansion by October 2022. The AAMC joined other hospital and health system groups in a Nov. 1 letter urging House Speaker Nancy Pelosi (D-Calif.) and Senate Majority Leader Chuck Schumer (D-N.Y.) to remove the provision. “These payments remain important for all hospitals and the patients they serve – and they remain especially important in those states that did not expand their Medicaid programs,” the letter stated.

    The legislation also addresses prescription drug costs, a key Democratic priority. A newly added provision would direct the Department of Health and Human Services secretary to create a new Drug Negotiation Program to help reduce spending and out-of-pocket costs for prescription drugs. Under the program, the secretary would negotiate a maximum price of certain high-cost Medicare Parts B & D prescription drugs beginning in 2025. The drug pricing policy would also cap seniors’ out-of-pocket costs for prescription drugs at $2,000 beginning in 2024. Along with additional drug pricing-related policies in the package, the administration estimates that the various drug-related policies would save $250 billion.

    The manager's amendment restores $500 million in grants for medical school and branch campus infrastructure, a provision that was included in the committee-passed bill but removed in the text released one week ago. These grants, which were first introduced in the AAMC-endorsed Expanding Medical Education Act (H.R. 801), would be dedicated to improving medical school infrastructure, constructing new branch medical campuses, recruiting diverse faculty and students, developing new curriculum, and planning for accreditation [refer to Washington Highlights, May 5].

    Additionally, the manager’s amendment to the BBBA expands an immigration process, known as “parole,” which would waive immigration requirements for five years for an estimated 7 million individuals who are undocumented, provided they have been living in the U.S. since 2011 (including those previously approved for Deferred Action for Childhood Arrivals or “DACA”). Once approved, beneficiaries could apply for work authorization, adjustment of status, and/or a five-year parole extension. The bill also increases fees for a number of visa categories. Even if the House passes the bill including this provision, immigration reform is still subject to review by the Senate parliamentarian, who decides whether the policy can be included in budget reconciliation.

    The manager’s amendment to the BBBA also would provide the National Health Service Corps with $2 billion in supplemental funding, and Children’s Hospitals GME with $200 million in supplemental funding, both increases from previous versions of the legislation. The manager’s amendment also removed a provision from the previous version of the legislation that would modify the endowment excise tax for private institutions.

    Finally, the manager’s amendment would reallocate  $7 million out of the $3.5 billion provided to the National Science Foundation to the agency’s Office of Inspector General for administrative expenses relating to the oversight of NSF funds.

    The House is expected to consider the legislation Nov. 5. After passing the House, the legislation would go to the Senate where it is likely to undergo further revisions and parliamentarian review.