The National Health Service Corps: "Essential" but Unseen

April 2000

With its ten-year authorization soon to expire, the National Health Service Corps is hearing praise from veteran health care advocates but little promise from Congress of a reauthorization before the close of the legislative year.

     Spokesmen invited by the Capital Area Rural Health Roundtable to talk April 12th about obstacles to getting the Corps into more rural areas, lamented the program’s low national profile and lauded its role in the nation’s health care safety net.  Speakers for the April session of the Roundtable were: David Sundwall, M.D., chair of the Council on Graduate Medical Education; NHSC Director Don Weaver, MD; Oklahoma state senator, Angela Monson, chair of the NHSC National Advisory Council; and Bill Finerfrock, director of the National Association of Rural Health Clinics.

     The Corps is a 28-year old, $116.9 million  federal program that uses scholarships, loan repayments, and a service mission to interest and recruit health professionals to communities that are too poor, sparsely populated or remote to attract enough providers.  While 20 percent of the U.S. population lives in rural areas, only 9% of the physician workforce practices in rural locations.  The program operates in both urban and rural settings, but 60% of its placements are rural.

Not a Household Name
     Wondering aloud why “we have a public delivery system that is nearly invisible,” COGME’s Sundwall called the NHSC a “national treasure that should be showcased.”  The former Reagan appointee who once headed the Health Resources and Services Administration — the Corps’ home agency — said the program “is not a competitor” with the private sector. 

      The Peace Corps and even the recently-created AmeriCorps are better known programs of public service than the National Health Service Corps, acknowledged NHSC director, Don Weaver.  He said the Corps’ cadre of 2,500 clinicians serve in every state and U.S. principality, from New Brunswick, Maine to the Pacific Basin.  But people are unaware of them because they don’t wear a special insignia or uniform and the clinics and offices where they work don’t necessarily advertise the presence of a Corps clinician. Yet they serve the “neediest of the needy” and they “go where others choose not to go,” said Weaver.

    The NHSC of today is very different than the program first created in 1972, according to its director, who was asked to explain how the Corps works.  Weaver said considerable effort now goes into matching practitioners with communities and into helping communities determine their clinician needs.  The NHSC responds to requests from communities designated as shortage areas for primary care, dental health, or mental health care according to complex sets of criteria that look at factors such as physician-to-population ratio, poverty, and low birth weight or infant mortality rates. 

     Corps clinicians are not federal employees, said Weaver.  They receive scholarships or loan repayments in return for their service commitments, but they are paid by the clinics where they serve.  Traditionally, the program has placed many Corps clinicians in federally supported community and migrant health centers, which have a mandate to serve vulnerable populations.
The NHSC has also developed an emphasis on interdisciplinary practice and cultural competence, according to Weaver, who added that its ethnic composition more closely reflects the nation’s than does the national healthcare workforce.   The Corps places not only physicians, but nurse practitioners, physician assistants, and certified nurse midwives; dentists and dental hygienists; psychiatrists, psychologists, social workers, marriage and family therapists, and psychiatric nurse specialists.

      Weaver said the Corps has recently expanded its output of badly needed dentists and mental health practitioners, which has required cutbacks in other areas.  Program administrators work with communities to study their needs.

No More Squeeze to the Orange
     The National Health Service Corps has been “a good return on investment,” Weaver told his audience, but the program needs more flexibility to meet national needs.  He said millions of Americans have received care that would not otherwise be available; 20,000 clinicians have served since 1972 and 97 % of them have fulfilled their service commitments.  About 50 %, he said, decide to continue serving the poor or work in medically underserved areas, following their period of obligation.  But Weaver said the program meets only 12.5 % of the national need for practitioners in communities designated as underserved.  Given its flat funding for the past five years, the program cannot field more than the 2,500 clinicians it now has, he said.  “There is “no more squeeze left to this orange.”

     The need for a national strategy to encourage physicians and other providers to practice in hundreds of communities across the nation became apparent more than 25 years ago, according to COGME’s Sundwall, when a national push to graduate more doctors helped overcome feared shortages, but only in certain regions.  He said that since 1950, when public policy focused on feared shortages, the overall physician to population ratio has increased from 142 per 100,000 to 274 per 100,000 population.
     
     But physicians have tended to specialize and to locate in amenity-rich communities, which has resulted in both surpluses and geographic scarcities.  The hundreds of communities designated as shortage areas have a ratio no better than one physician for every 3,500 residents.  The public health service recommends a minimum ratio of at least one for every 2,500 population. The Council on Graduate Medical Education was authorized in 1986 by Congress to sort out the confusion over supply, said Sundwall.  Its 17 members represent physician organizations, medical schools and teaching hospitals, insurers, business, and labor.

Increase of Shortage Areas 
     Apologizing for his exclusive focus on physicians, given the growing role of nurse practitioners and physician assistants in primary care, the COGME chairman said the nation still has a recalcitrant problem of maldistribution.  Pointing to bar charts from the COGME’s 10th Report of February 1998, he cited what he called an “extraordinary paradox:”  The number of physicians
has gone “up and up” to more than 700,000 while the number of primary care shortage areas has not diminished, but exceeded 2,000 in the past decade. “We could quibble about how shortages are calculated, but I don’t think the trend can escape anyone,” said Sundwall.

     Along with recommendations to expand health insurance coverage and improve data collection for shortage assessment, COGME’s 1998 recommendations call for significant increases to the National Health Service Corps as well as support for other state and federal safety net programs. 
Sundwall said he personally thinks a doubling of the Corps might “possibly be sufficient.”  He said the COGME will be making a recommendation on numbers in the near future.  He also said the panel’s latest report, its 14th, shows that 19 states have enacted legislation to address health workforce issues.

Need to Mesh With State Programs
     Oklahoma State Senator Angela Monson, who chairs the NHSC’s National Advisory Council, offered perspective on the NHSC from the vantage point of her state, which has initiated a number of its own programs to meet rural provider deficits.  About a third of the state is rural, and the incidence of uninsurance in some rural counties is as high as 50%.  

     “The health care payer base in rural Oklahoma is not a pretty picture,” she said, and “attracting physicians to rural Oklahoma is extremely tough.”  To remedy that problem, the state created a Physician Manpower Training Commission in 1975 that operates four placement incentive programs with a budget of $1.6 million for scholarships, stipends, and loans.  The programs employ a homegrown approach by focusing on rural Oklahoma youth interested in returning to their communities as practitioners.  The assistance is tax-free, in contrast to NHSC scholarships and loans, which are not.  She said the Oklahoma Rural Medical Education Scholarship, for example, provides $42,000 over 4 years and requires only that recipients practice in an  Oklahoma community of fewer than 7,500 people. The program has yielded 105 practitioners who have remained beyond their commitments.  A newer program, the Family Practice Resident program, offers stipends to residents who agree to practice in an “underserved rural community,” and has 22 current obligees practicing. 

     The senator underscored the state commission’s “advantage of flexibility” in using a broader state definition of underservice specific to rural need, in contrast to the National Health Service Corps’ point system for determining greatest need through such measures as mortality rates or ethnicity.  The national outcome of the Corps’ priority measures said Monson, is that the Corps can “do a bang up job in some states while others only have eight or nine” NHSC practitioners.  Oklahoma could use many more NHSC practitioners than it has, said Monson, if only the national program could have flexibility to work with the state programs. 

     Asked later by attendee Gil Hill of the American Psychological Association if states were ready to help communities study their provider options, and if the Corps is ready to work with state partners, Monson and Weaver responded affirmatively.  Most states are short of staff, said the Oklahoma senator, and would welcome the Corps’ support in working with communities. She said the NHSC could also reach more areas if it had more placement freedom, such as in private practices where the rates of uninsurance are high.  The bottom line, she said, is still the need to reauthorize the NHSC.  “I view it as fundamental to achieve...we will not be successful without the Corps.”  The NHSC Advisory Council, which Monson chairs, has made a series of recommendations for increasing the Corps flexibility that includes a research, development, and demonstration authority,  and making Corps scholarships and loans tax free.

A Range of Options
     Bill Finerfrock, who directs the National Association of Rural Health Clinics spoke of the unfinished work ahead for rural advocates in making the National Health Service Corps a “stronger, more viable and efficient” program for serving unmet health care needs. Finerfrock said long-term solutions will require the coordination of both workforce and insurance initiatives, adding that Medicare and Medicaid should be better paired with programs like the NHSC.

     Finerfrock’s association of rural health clinics represents physician practices that qualify for cost-based reimbursement under Medicare because of their location in physician shortage areas and their use of nurse practitioners and physician assistants.  He said a coalition of 18 national provider organizations are involved in some “good will hunting” to reach consensus and identify ways to strengthen the NHSC program.
     
     He displayed national maps of rural counties showing the distribution of the NHSC, Community Health Centers (CHCs), and Rural Health Clinics (RHCs), in rural counties throughout the United States.  Pointing to large regions where there are no Corps practitioners but many Rural Health Clinics, he said, “We do have a lot of areas of the country defined as underserved by the federal government where we could potentially have Corps placements.” Offering another view by numbers, Finerfrock said 1,506 of the nation’s 2,200 non-metro counties were entirely or partly designated in 1998 as shortage areas.  Only  485 rural counties have Corps practitioners, according to the data he offered, which he said is available, along with maps, from the University of North Carolina Rural Health Research Center website.  [See www.shepscenter.unc.edu]

Clarifying the Mission
      Finerfrock said the fact of growing numbers of official Health Professional Shortage Areas (HPSAs) prompts questions about the Corps’ mission and the basis for measuring its success — whether the goal is to support communities that can’t attract a permanent practitioner, or seed those that can.  “I don’t think that issue has really been debated and decided within the Congress,” he said.  The “reality of the mission is both…but  “we need to have that debate and discussion and we need to give the Corps the flexibility to meet the needs of different types of communities.” 

     Echoing Weaver’s discussion of possible options, Finerfrock talked of allowing Corps clinicians to repay their obligations on a part-time basis, which, he said, could meet the needs of communities unable to support a full-time practitioner.  He said another concept for creative use of the Corps might be for locum tenens in the form of a “ready-reserve” workforce that can relieve isolated and beleaguered rural practitioners  — fulfilling a weekend a month obligation, “much like our military reserve.”

     Finerfrock also emphasized a need for “site development,” a collaborative process that he said helps communities take a thorough look at their options.  “While every community may say, ‘we want a physician,’ the reality may be that not every community necessarily needs a physician.  The community may need a mental health professional...the community may be better served by a nurse practitioner that could better lead to a long-term solution.”

     Another option under discussion but not addressed at the forum, has been a proposal to ease or remove the program’s legislative requirement to set-aside 10 % of its recruitment budget for scholarships to mid-level clinicians.  Under the set-aside, 45% of the scholars are nurse practitioners, physician assistants, and certified nurse-midwives.  The proposal has stirred controversy in the rural and provider community, challenging the effort to reach consensus.
 

Center for Health Policy Research & Ethics 
George Mason University 
Fairfax, Virginia 
February 2000