Legislators love a good acronym when it’s time to name a bill. That’s one truism you remember when you look at something recently introduced in the U.S. House of Representatives that’s of enormous potential benefit to the nation’s health care and the future of family medicine.
I’m talking about the (deep breath) Creation of Opportunities for Medical Manpower in Underserved Neighborhoods by Indemnifying Tuition and Incentivizing Exceptional Service Act (H.R. 4285). Via funding for the National Health Service Corps’ loan repayment program, the bill would cover 100% of medical school debt repayment for primary care clinicians who work five years in an eligible underserved community.
Full loan forgiveness is a big deal, but pronouncing FLF sounds a little dismissive, so COMMUNITIES Act it is — and COMMUNITIES Act the Academy supports. The legislation would “help strengthen the primary care physician pipeline, increase access to health care to communities in most need, address medical school debt burdens and help ensure wider access to medical education opportunities,” the AAFP said in a July 7 letter to its sponsor, Rep. Bobby Rush, D-Ill.
As they are structured and funded now, NHSC repayments — $50,000 for two years and up to $100,000 for five years in some cases — do not cover the full cost of medical school. Not even close, given that the average debt load for graduating students is $200,000 to $250,000. That shortfall is even more alarming given research showing that loan forgiveness or repayment programs directly influence physician specialty choice. Meanwhile, we continue to stare down the barrel of a projected primary care shortage of some 48,000 physicians by 2034.
Rep. Rush gets it. In a press release his office issued to accompany introduction of the COMMUNITIES Act, he said, “Right now, many underserved communities, including on the South Side of Chicago, are suffering from an acute lack of primary care physicians, and specifically, physicians of color. Studies show that Black patients have better outcomes when treated by Black doctors, and that Black doctors are less likely to harbor implicit racial biases that can harm patients of color.”
To further build on Rush’s efforts to decrease medical student loan debt in general and among communities of color in particular, the Academy earlier this year also endorsed the Strengthening America’s Health Care Readiness Act (S. 54), which would provide a one-time supplemental investment in the NHSC program to help meet the challenges highlighted by the COVID-19 pandemic. The bill also would set aside funding to recruit physicians from racial and ethnic minorities and students from low-income urban and rural areas. Particularly in the wake of the COVID-19 pandemic, Academy leaders are highly attuned to this issue, this shortage within a shortage. The effects are real and significant. For example, a study published in 2018 suggests that an increase in the number of Black physicians could reduce the Black-white male gap in cardiovascular mortality by 19%.
This year’s American Rescue Plan Act increased NHSC funding by $800 million, a boost the Academy welcomed and one that positioned the office to make its most-ever awards in a single year. And its central role in the COMMUNITIES Act is well in line with longstanding AAFP policy goals. As AAFP President Ada Stewart, M.D., a former NHSC scholar, said this past spring, “We’ve advocated for reauthorization and appropriate funding of the National Health Service Corps for many years. We have to look at the importance of addressing our future workforce issues in addition to addressing health care disparities. The National Health Service Corps is a means to do both.”
For now, the legislation has relatively few co-sponsors. But the AAFP’s Center for State Policy tracked student-debt-related bills in more than 15 states this year and found some promising activity.
Arizona’s governor signed legislation, passed there in March, building on an existing program there aimed to place physicians in rural federally designated health professional shortage areas or medically underserved areas. Practitioners are eligible to receive up to $65,000 of loan-repayment funds for their first two years of service, then $35,000 annually for subsequent years.
Awaiting the governor’s signature in Delaware is legislation creating a loan-repayment program for new primary care physicians who work in underserved areas and accept Medicaid and Medicare patients. That one allows up to $50,000 a year for four years.
Out west, a powerful example of loan repayment progress achieved with the support and participation of family physicians is CalHealthCares. That program devotes several hundred million dollars a year to medical school debt, with two-thirds of the awards going to physicians (and the other third to dentists). Among the physicians’ share, half goes to subpecialists and half goes to primary care physicians. And the California AFP, which advocated for CalHealthCares and sits on its advisory committee, tells me that 45 percent of the program’s primary care recipients are family physicians.
Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.