To the Editor:

The Graham Center Policy One-Pager on community-based residency training underscores the slow but promising rise in nonhospital residency pathways.¹ Yet, achieving a sustainable and equitable distribution of the primary care workforce demands two strategic shifts beyond awareness: stable outcome-linked financing and transparent accountability for workforce retention in underserved areas.

Teaching Health Center programs have demonstrated measurable impact. A decade-long evaluation found that 56% of Teaching Health Center graduates practice within 5 miles of their training sites, and nearly 60% serve in Health Professional Shortage Areas—significantly higher than traditional residencies.² However, the continuation of these benefits hinges on consistent funding. Intermittent appropriations reduce retention stability and limit long-term planning capacity.³

We propose three implementable policy levers to advance the conversation begun by Manfredonia and Huffstetler's Graham Center Policy One-Pager.¹ First, states should designate a Medicaid graduate medical education (GME) set-aside (eg, 5% of state GME funds) earmarked for community-based programs contingent on verifiable workforce metrics. Second, the federal government should establish multiyear GME block grants to community sites, mirroring hospital GME entitlements, with disbursement tied to placement and retention outcomes. Third, the Health Resources and Services Administration and state Medicaid agencies should jointly publish a public workforce dashboard detailing practice location, specialty, and patient population within 3 years of graduation, ensuring transparency and enabling performance-based reinvestment.

Evidence from state initiatives supports this financing-and-metrics framework. Programs that redirect Medicaid GME toward outpatient sites (eg, California's Song-Brown initiative) achieve higher retention in shortage areas when coupled with predictable multiyear funding and clear outcome reporting.^4,5 Embedding measurable accountability into funding would transform short-term pilots into sustainable systems that meet the nation's primary care needs.