Iowa AFP Pushes State Into Enacting Primary Care Student Loan Repayment Program

The Iowa Academy of Family Physicians (IAFP) has earned a reputation as a savvy political player within the halls of the Iowa legislature during the past few years. In 2011 alone, the IAFP and its legislative allies succeeded in halting a Medicare physician payment cut and stopping midlevel providers from obtaining independent practice authority.

But the chapter's greatest legislative victory came in 2012 as a result of legislation that created a physician loan repayment program designed to encourage more medical school graduates to pursue careers in primary care and to increase the number of primary care physicians, including family physicians, practicing in rural parts of the state. The legislation establishes a loan repayment program for primary care medical students who agree to stay and complete their residencies in the state and to practice in small, rural communities for at least five years after residency.

In helping to enact the legislation, the IAFP played a major role in addressing one of the state's most vexing problems: the lack of primary care physicians in rural areas. For its efforts, the AAFP awarded the IAFP a State Advocacy Leadership Award during the Academy's State Legislative Conference in Memphis, Tenn., last November.

"We were able to convince various interested parties, including the legislature, that we have a problem," said Donald Skinner, M.D., the family physician who led much of the efforts to pass the legislation. "We also presented a viable solution."

As a predominantly rural state, Iowa long has confronted a shortage of primary care physicians, especially in rural areas. "Most Iowa physicians and midlevel providers practice in urban and suburban communities, leaving rural, border and inner-city communities without adequate access to quality primary and preventive care," said Pam Williams, EVP of the IAFP.

By 2011, the situation had reached a crisis point, as demonstrated by the fact that

At the same time, the number of U.S. medical graduates choosing to enter primary care residencies has fallen by nearly 50 percent during the past 10 years -- a statistic that has profound implications for Iowa because the average age of primary care physicians in the state is 48, one of the oldest in the country, according to the IAFP. If current trends continue, there will not be enough primary care physicians to take the place of current physicians who will reach retirement age within the next 16 years, said Steve Richards, D.O., past president of the IAFP and the Iowa Medical Society.

"The number of years we have left is diminishing, making workforce even more of an issue," said Richards.

In 2011, the IAFP convened a task force to address the workforce issue. The task force quickly identified medical school debt and wide income disparities between primary care physicians and subspecialists as the two biggest reasons why medical students choose subspecialties instead of primary care.

The task force, which is made up of IAFP's executive and advocacy committees, as well as residency directors in the state, determined it could not do much about the income disparities. But members could address the issue of student debt by pushing for establishment of a loan repayment program to ease and perhaps even eliminate medical school debt for students who want to pursue careers in primary care in rural areas of the state.

The IAFP task force and the IAFP's lobbyist, David Adelman, began researching how other states addressed primary care workforce shortages through legislative action, ultimately incorporating legislative language from a number of other states into the loan repayment proposal.

"I don't think you ever want to recreate the wheel," said Adelman. "You want to take programs that have worked in other states and mold them into what will work for yours. There is not one state legislature that is the same, but there are some commonalities and similarities you can model from."

Before getting the proposal introduced in the state legislature, Adelman and other members of the IAFP met with lawmakers and representatives from the governor's office to familiarize them with the initiative. They then identified primary care supporters in the House and Senate and convinced lawmakers to introduce the bill in both chambers to increase the likelihood of final bill passage. Skinner served as the chair of the IAFP's workforce committee and the IAFP's board of directors during this time and, thus, played a key role in convincing lawmakers of the need for the repayment program.

The IAFP had a daunting task from the outset. According to Adelman, Iowa is represented by a "citizen's legislature" meaning that state lawmakers are not full-time legislators. In addition, no legislator at that time came from a physician background. Adelman also noted that the Iowa legislature is conservative by nature and very reluctant to fund new projects.

"No one disagreed with the premise and the need," said Williams. "It would be like being against motherhood and apple pie by saying, 'You don't want to keep physicians in Iowa, practicing in rural communities.' But allocating funding for it is an entirely different matter."

As soon as the legislation was introduced, the IAFP began rallying its members in support of the bill. They found family physician members in every one of Iowa's congressional districts who could contact their representatives in support of the legislation. "The legislators see me every day, and they knew this issue is important to my client," said Adelman. "But when they heard from local physicians, they knew this was important to them, as well."

In appeals to lawmakers, the IAFP stressed the long-term benefits of the legislation by pointing out, for example, that medical students who complete their residencies in Iowa are much more likely to stay in Iowa than medical students who go through residencies outside of the state.

"We wanted to find a way of keeping them in the state, so having this loan repayment program with a commitment to practice in a rural area is a way of getting physicians into rural areas and keeping them in Iowa after that," said Williams. "If they leave Iowa to go to residency, they do not come back."

Although the final measure pertains to all primary care physician specialties, the IAFP knew the legislation primarily would benefit family physicians, according to Williams. "The majority of people who go into the primary care shortage areas are family physicians," she said. "It was a win-win to include the (other primary care specialties), but it is still likely to benefit family medicine residencies more because they are the ones who go out (to rural areas)."

The IAFP also touted the economic benefits of the legislation in interactions with lawmakers, focusing on the return on investment, which resonated with House and Senate members.

The legislation calls for providing 20 primary care medical students with as much as $50,000 a year per student, which essentially would eliminate medical school debt for those 20 students who agree to abide by the program's terms. The IAFP presented data from the U.S. Department of Labor showing that a family physician, on average, generates $934,000 in revenue for his or her particular community each year, while employing 6.2 people.

"That return on investment is significant," said Adelman.

The IAFP also defeated attempts to include subspecialists in the loan repayment program by arguing successfully that there is a greater need for primary care physicians in the state than subspecialists, especially since primary care physicians serve as the foundation of the nation's health care system.

"Everyone and their mother wanted in on this (legislation)," said Adelman.

When the legislature approved the loan repayment legislation last year, the House stripped funding from the bill, handing the IAFP a seemingly hollow victory. But the IAFP refused to give up, and in the final hours of last year's legislative session, chapter members managed to obtain $105,000 in funding for the initiative from the legislature. That's a far cry from the millions needed to truly implement the program, but it is enough to get the initiative started and move it forward, according to Adelman.

The IAFP continued to work with the governor's office after the legislature adjourned for the year in 2012, eventually convincing the governor to make funding for the loan repayment program one of three top priorities that he announced during his annual Condition of the State address. As a consequence, the governor put $2 million for the program in his current budget, greatly enhancing the chances that the legislature will approve the $2 million in funding because the money is already in the governor's budget, said Adelman, who describes the governor's request as a "phenomenal step in the right direction."

"We are obviously not going to solve the primary care physician shortage crisis overnight," said Adelman. "We are building an infrastructure, and it is going to take time."