The federal government spends nearly $30 billion annually to finance residency training for physicians in the United States, largely through Medicare and Medicaid. Despite this substantial public investment, there is little effort made to ensure that the physician workforce produced aligns with population health needs.
And it shows: Americans are finding it increasingly difficult to access primary care. Many communities, especially rural and underserved areas, face shortages of primary care physicians, long wait times, fragmented care, and a lack of meaningful relationships between individual patients and clinicians over time. These access challenges are due in part to persistent primary care physician shortages and imbalanced distribution, outcomes of an education and training system that prioritizes specialists over generalists and academic medicine over community training
Sweden designed a different approach.
Sweden is aligning primary care access goals with physician workforce policy more explicitly. Rather than treating physician training as separate from care delivery, Sweden is using workforce policy as a tool to strengthen continuity, accessibility, and person-centered primary care. To support this goal, the Swedish National Board of Health and Welfare analyzed primary care workload and physician capacity, established a benchmark of one primary care physician per 1,100 residents, and issued recommendations to guide regional workforce planning toward that target.
The result is not a perfect system. Sweden, like the United States, continues to struggle with shortages of family physicians and uneven access across regions. But Sweden’s recent reforms offer an important lesson: primary care access goals become more achievable when governments intentionally align workforce planning, physician training, staffing benchmarks, and accountability.
At the center of Sweden’s reforms is the idea of “permanent physician contact” — an ongoing relationship between a patient and a primary care physician. Swedish residents have the right to choose a permanent primary care physician. The goal is to improve continuity, trust, coordination, and participation in care.
Between 2021 and 2025, the Swedish National Board of Health and Welfare developed a framework supporting permanent primary care physician contact, including workforce benchmarks, implementation monitoring, and regional workforce planning.
Historically, Sweden’s 21 regional health systems — which are responsible for organizing and financing care —had approached physician workforce issues independently. As Swedish family physician leader Andreas Stomby recently observed, “Each region, hospital, even clinic has had the mandate to offer residency positions, without considering the bigger picture — where do physicians need to work to build a strong health care system?”
The United States faces a similar problem. Although physician training strongly influences where physicians ultimately practice and what specialties they choose, federal graduate medical education (GME) financing remains largely tied to algorithms based on hospital funding patterns established decades ago. The Centers for Medicare and Medicaid Services lacks authority to measure workforce outcomes associated with the nearly $21 million in Medicare funding that supports physician training. The result is a system that often produces workforce outcomes misaligned with patient needs, specifically not enough primary care physicians, general surgeons, and psychiatrists.
Sweden’s recent reforms suggest a different model: define national access goals first, then align workforce policy around them. Sweden also invested in implementation infrastructure. In 2025, the National Board of Health and Welfare appointed a national coordinator to guide regional implementation. This included site visits, regional dialogues, and workforce action plans. By late 2025, 18 of Sweden’s 21 regions had formally adopted the national guideline, and all regions had either completed or begun developing workforce action plans tied to permanent physician access goals.
The reforms also increasingly connected workforce planning with physician training policy. Regions that made the greatest progress invested in recruiting and retaining family physicians, expanding family medicine training positions, strengthening supervision and mentoring, and creating more sustainable patient panel sizes.
Many of the governance challenges Sweden is now addressing have long been recognized in the United States. In 2014, the Institute of Medicine recommended a federal GME Policy Council and a GME Center within the Department of Health and Human Services to better align physician training investments with workforce needs. The Affordable Care Act also authorized a National Health Care Workforce Commission. Neither effort was funded or implemented.
As a result, the United States lacks a national mechanism for coordinating physician workforce policy across Medicare, Medicaid, the Health Resources and Services Administration, the Veterans Health Administration, states, accrediting bodies, and health systems. Sweden’s recent reforms illustrate what more active national stewardship can look like: shared goals, workforce guidelines, regional implementation support, and ongoing monitoring.
Sweden’s workforce policies cannot simply be transplanted into the United States, but several lessons are relevant for U.S. policymakers.
- Decisions about physician training are also decisions about access to care. Public investments in residency training influence where physicians practice and where shortages occur.
- Continuity in primary care requires deliberate workforce infrastructure. In the United States, decisions about where physicians train and which specialties expand are often driven more by hospitals’ financial and operational priorities than by whether communities have adequate access to care. As a result, publicly financed physician training has historically produced a workforce concentrated in urban areas and subspecialty care despite persistent shortages in primary care and in rural and underserved communities.
- National goals matter. Sweden’s benchmarks helped create shared expectations across regions while still allowing local flexibility in implementation.
- Meeting the access and workforce needs of the country requires coordination, accountability, and sustained implementation support — not simply funding.
The United States already has effective workforce investments, including teaching health centers, rural residency programs, and state-based GME initiatives. But these programs are often absent from states with the greatest access problems and remain relatively small and less securely funded than the broader Medicare GME system.
Sweden’s experience suggests that stronger alignment between workforce policy and health care access goals is possible. Guidelines alone do not eliminate physician shortages. Access improves when physician training, workforce planning, and accountability move in the same direction.
