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Iowa AFP Pushes State Into Enacting Primary Care Student Loan Repayment Program
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.
- The Iowa AFP successfully employed an advocacy campaign to help secure passage of legislation that creates a physician loan repayment program for medical students willing to practice as primary care physicians in rural parts of the state for five years after residency.
- By helping to ease the debt burden for primary care medical students, the measure addresses the state's ongoing shortage of primary care physicians in rural areas.
- The IAFP now is pushing for adequate funding for the loan repayment program.
"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."
Meeting the Challenge
By 2011, the situation had reached a crisis point, as demonstrated by the fact that
- 62 percent of Iowa's 99 counties are federally designated physician shortage areas;
- Iowa ranks 41st in the nation in terms of the ratio of physicians per 100,000 population, according to the AMA; and
- more than 73 counties need more primary care physicians.
Three Key Components of Successful Advocacy Efforts
In an interview with AAFP News Now, Adelman described successful lobbying efforts as a three-legged stool, saying that the first leg of the tool involves the organization that is supporting the legislation. "You are only as good as the organization that is behind you," he said.
The second leg involves membership advocacy, which entails a strong grass-roots component that encourages and gives physician members the opportunity to reach out to legislators and let them know what is important and why it is important.
The final leg of the stool involves identifying your friends in the legislature and taking steps to thank them, while also making sure they remain in the legislature through various means of support. This support can include contributions from the organization's political action committee, said Adelman.
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."
Facts About the Iowa AFP
Date chapter was chartered: 1948
Location of chapter headquarters: Des Moines
2013 annual meeting/scientific conference date/location: Oct. 31-Nov. 2, The Meadows Events & Conference Center, Altoona
"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.
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."
Iowa AFP Works to Ensure Continued Supply of Primary Care Docs