AAFP to Education Secretary: Bring Back the 20/220 Pathway

Heeding recent calls by family medicine residents, medical students and other stakeholders, the AAFP is urging the U.S. Department of Education to permanently reinstate the debt-to-income ratio -- known as the "20/220 pathway" -- of the economic hardship loan deferment.

The Academy recently joined 96 other medical specialty professional organizations and state medical societies in signing on to a letter (4-page PDF; About PDFs) that asks the department to restore the pathway permanently -- or to provide an equivalent funding mechanism for loan deferments -- so residents don't have to pay back their loans during the first three years of their training.

"What we want to do is maximize the amount of time that residents can defer these payments because of the tremendous amount of debt they're in," said (then) AAFP Board Chair Rick Kellerman, M.D., of Wichita, Kan.,

The 20/220 pathway allows qualifying medical residents to postpone repayment of their federal student loans -- which average a total of $140,000 -- for up to three years without accruing interest on the subsidized portion of those loans. The pathway gets its name from the qualification criteria residents must meet. Specifically, they must be employed full-time, their federal education debt must be 20 percent or more of their monthly income, and their income minus the debt must be less than 220 percent of the greater of the minimum wage rate or the federal poverty level for a family of two.

The letter to Education Secretary Margaret Spellings follows Congress' passage of the College Cost Reduction and Access Act last year and subsequent rules issued by the department. That legislation, signed into law by President Bush on Sept. 27, 2007, and scheduled to go into effect July 1, 2009, augmented the Higher Education Act by creating two new loan programs, but it did not bring back the popular 20/220 pathway.

Taking over under the College Cost Reduction and Access Act will be a new income-based repayment program. It caps the level of loan repayments based on a resident's income, but residents start making payments after graduating from medical school. If they want to defer payments, they have to enter forbearance, which is a temporary postponement during which interest charges continue to accrue.

The letter that the AAFP cosigned says high medical student debt is a "significant hardship throughout the loan repayment period, particularly during the three to eight years of training in medical residency programs," when the average first-year stipend is less than $45,000. Borrowers with high loan debt may be discouraged from entering primary care medicine or public health service or from practicing in underserved areas, the letter says.

Moreover, "Complicating student debt burden repayment could further deter students from pursuing a career in medicine, which could adversely affect our nation's access to care in the coming years," the letter says, noting the Council of Graduate Medical Education's forecast of a shortage of 85,000 physicians in the United States by 2020.

The letter should come as good news to family medicine residents and medical students, who vigorously registered their concern about the proposed loss of the 20/220 pathway during the 2008 National Conference of Family Medicine Residents and Medical Students. Both the resident and student congresses adopted resolutions urging the Academy to protest the elimination of the pathway and to state its opposition in letters to various executive-level officials, including the education secretary.

''Our nation already has a shortage of primary care physicians, and I think that without the 20/220 loan deferment program, this trend may be enhanced," Elizabeth Menzel, a fourth-year medical student at the Mayo Medical School College of Medicine in Rochester, Minn., recently told AAFP News Now. Menzel was a co-author of a resolution to the student congress on this topic.

Will Nicholson, M.D., a third-year resident at the University of Minnesota St. John's Hospital Family Medicine Residency Program in St. Paul, Minn., and a co-author of the resident resolution, agreed. "Patients need to know that in the middle of a national primary care crisis, the administration is engineering fresh roadblocks to training physicians in the most needed specialties," he told AAFP News Now.

After spirited testimony on this topic by family medicine residents, medical students and new physicians during the 2008 AAFP Congress of Delegates last month, the delegates adopted a resolution calling on the AAFP to advocate reinstatement of the pathway, or institution of an equivalent mechanism, for physicians entering primary care specialty training.