The Balanced Budget Act of 1997 and continuing changes put into place by the Educational Commission on Foreign Medical Graduates (ECFMG) are altering the environment for graduate medical education (GME) in ways that threaten osteopathic graduate medical education in particular. Hospital revenue is decreasing due to declines in Medicare GME and patient-care reimbursements. The new 3-year rolling average methodology for counting "house staff" makes it likely that unfilled positions will be eliminated. With osteopathic GME positions unfilled and financial resources decreasing, osteopathic medical programs may shrink further. Additionally, the ECFMG has put into place policies that may restrict the number of international medical graduates entering the United States. Approximately 25% of all allopathic GME positions in the United States are filled by international medical graduates. If this applicant pool decreases, allopathic medical programs may turn to osteopathic medical graduates as the only other available pool of individuals to fill program positions. At a time when allopathic internship positions are already unfilled and 30% of osteopathic medical graduates enter allopathic first-year programs, further inroads by allopathic programs could severely impact osteopathic GME efforts.