CHCs Struggle With Physician Shortage

The AAFP was right. Slashing federal support for Section 747 of Title VII of the Public Health Service Act threatens the viability of the very programs touted as the solution to inadequate health care access. Moreover, continuing current policy could lead to a nationwide shortage of primary care physicians.

That's the conclusion drawn in a March 1 Journal of the American Medical Association research article and an accompanying editorial that point to the importance of continued funding of Title VII, the federal program that provides funds to academic departments and programs to increase the number of primary care professionals.

Among Title VII's goals is ensuring physicians are available to staff community health centers, or CHCs. These centers, most often located in rural or inner-city medically underserved communities, are recognized as a key part of the health care safety net in the United States.

The research article, "Shortages of Medical Personnel at Community Health Centers: Implications for Planned Expansion," examines the status of the workforce in CHCs and the implications for the centers' growth. The Bush administration has called for expanding the centers since 2001. The federal Health Center Initiative passed in 2002 and established a five-year, $780 million program to create new or expand existing CHCs in medically underserved areas.

Such growth, however, cannot occur or be sustained without medical personnel -- particularly family physicians -- to staff the centers. And, with 400 family physician vacancies in existing clinics, the initiative is bound to stall, said the researchers.

"This study suggests workforce shortages may impede the expansion of the U.S. CHC safety net, particularly in rural areas," write FP Roger Rosenblatt, M.D., M.P.H., vice chair of family medicine at the University of Washington School of Medicine, Seattle, and his co-authors. A continued decline in the number of family physicians "may lead to renewed shortages of safety net and rural physicians generally."

In fact, write the authors, the shortage of family physicians in community health centers may lead to serious problems in the overall health care system. "The ongoing expansion of CHCs, coupled with decreasing production of primary care physicians, suggests that workforce shortages may become more important in years ahead," they note.

Dan Hawkins, policy director at the National Association of Community Health Centers, agreed. "This is a story for all Americans, not just for those living in rural and inner city communities," he told National Public Radio's Julie Rovner during a March 1 "Morning Edition" interview. "And not just for health centers. We are the canary in the coal mine. We are the ones who can point to what's happening."

In their article, Rosenblatt and his co-authors take aim at current federal policy, pointing to a declining emphasis on programs that recruit medical students from rural and underserved areas. "One of the most effective ways to attract rural health professionals is to train people from rural backgrounds in programs with a rural emphasis," they write. "Unfortunately, declining emphasis on these programs and the decrease in the number of rural students applying from and being accepted to medical schools portend greater difficulties for CHCs and other clinical entities in attracting adequate personnel."

Much of that declining emphasis has come in the form of severe reductions in support for Title VII, the authors say. "This is the only federal program that exists to encourage the production of primary care clinicians likely to practice in underserved areas and has been successful in improving the supply of primary care practitioners in underserved settings, but its proposed funding has decreased substantially," they write.

In fact, Presidents Bush and Clinton each recommended zero funding for Title VII in their budgets, but until last year, Congress overrode those budgets, allocating $88 million for the program as recently as 2005. Last year, however, Congress slashed Title VII funding for 2006 to $41 million. The program again has been recommended for zero funding in President Bush's 2007 budget.

The Bush administration contends Title VII programs haven't been effective in steering physicians to work with the underserved. The program, however, was launched to increase the number of primary care physicians nationwide rather than to meet the needs of the underserved population, say health policy-makers.

"I think the administration hasn't got a clear, comprehensive picture about how all these parts are tied together," Rosenblatt said during the March 1 NPR broadcast. "You have to have a workforce to provide the care. Just having an edifice or the organization isn't enough."

That position was supported in the JAMA editorial, "Strengthening Primary Care to Bolster the Health Care Safety Net," by Christopher Forrest, M.D., associate professor at The Johns Hopkins Schools of Public Health and Medicine.

"Without the strong advocacy from such organizations as the American Academy of Family Physicians and the Association of American Medical Colleges, Title VII may not be funded today," he wrote. "Ensuring sustained and enhanced financial support for Title VII is critically important and must be a legislative priority."