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Treating the underserved: You call this an incentive?


A federal program to encourage physicians and others to work with the poor is in trouble. Critics charge Congress with turning a blind eye.


Short Takes

Treating the underserved: You call this an incentive?

A federal program to encourage physicians to work among the poor is in trouble. Critics charge Congress with turning a blind eye.

By Wayne J. Guglielmo
Senior Editor

FP Christopher J. Fellenz took a leave of absence while in medical school to help care for poor patients in Mexico, Central America, and South America.

So it came as no surprise that after completing his residency at Denver's Clinica Campesina Family Health Services—a community health center serving the city's large Hispanic population—Fellenz was eager to stay on. The new position, which he began in January 2000, also made him eligible for a federal program that rewards doctors working in underserved areas with up to $25,000 per year in school loan repayments.

But after applying last February to the National Health Service Corps Loan Repayment Program, Fellenz and a colleague at Clinica Campesina waited until October before they learned they wouldn't receive any money in 2000. "Like a lot of people, I assumed that if I was working in an underserved area and was eligible for a loan repayment, I'd get it," Fellenz says today.

That incorrect assumption has led to a lot of bitterness among many physicians and other health professionals working in what the government calls health professional shortage areas. Indeed, for fiscal year 2000, the loan-repayment program received 715 new applications from primary care physicians, dentists, dental hygienists, physician assistants, nurse practitioners, and certified nurse midwives. Fewer than half received new awards, leaving 378 eligible candidates—including 67 physicians—out in the cold.

Federal officials aren't surprised the money ran out. "This happens every year," says pediatrician Marilyn Hughes Gaston, the associate administrator of the Bureau of Primary Health Care of the Health Resources & Services Administration, which oversees the $35 million loan program. "The money was never promised to begin with," she continues, adding that the program could do a better job of managing applicants' expectations.

Still, last year's shortfall was the worst in the program's 28-year history. Several factors contributed to this: HHS budget cuts to meet the demands of the Balanced Budget Act of 1997, the need to make good on outstanding awards from 1999, and the granting of over 260 incentive awards aimed at retaining professionals already in the program.

An emergency infusion of money from Congress would have helped. But given lawmakers' preoccupation last session with the election and other matters, additional funding was a low priority. By year's end, the House had passed a small funding increase, but NHSC itself—which officially expired last Sept. 30—still awaits Congressional reauthorization.

That's likely to come this session, but advocates want any reauthorization bill to include a sizable funding boost. "We feel there should be more funds not only to pay the people who didn't get loan repayments last year, but to help increase the number of health professionals practicing in underserved areas," says San Diego internist Rodney G. Hood, president of the National Medical Association, which represents more than 20,000 African-American physicians.

The NMA, says Hood, has already received verbal commitments from members of the Congressional Black Caucus that they would take up the issue of increased funding this session. Internist Elena Rios of the National Hispanic Medical Association says her organization is also "very supportive" of the program and efforts generally to increase minority access to medical care.

For many involved in community health, those efforts can't come fast enough. "This is a very serious situation for the medically underserved areas," says Lorna McBarnette, chief executive officer of the Community Health Care Association of New York State, which represents community health care centers across the state. "The loan-repayment program was our source of getting doctors into rural and inner-city areas where we have shortages."

If young doctors assume that source has dried up, McBarnette and other observers say, they're likely to think twice about working in underserved areas after medical school. "Several recruitment efforts I know about already have gone awry," says McBarnette. The problem is especially acute for physicians of color, she adds, "many of whom have gone to school with the expectation of receiving loan repayments in return for working in the inner cities." Funding shortages, she says, could cause them to rethink their options.

For physicians like Chris Fellenz, who are already working in underserved areas, funding shortages make it harder to stay. "I'm actively looking for other opportunities," admits Fellenz. He has heard from several groups that care mostly for insured patients. Though his preference is "to stay in the kind of setting I'm presently in," he realizes that he may not be able to afford to remain at a clinic serving the poor.

And doctors aren't the only ones facing this agonizing choice.

Deborah Herdan, a certified nurse midwife working at Jacobi Medical Center in the Bronx, NY, took her current job in 1998 expecting that part of her midwifery school debt would eventually be offset. (As a National Health Service Corps scholarship recipient, Herdan already received a one-year tuition reimbursement in exchange for a two-year service obligation.) She plans to apply for the loan repayment next year. "I certainly wasn't told by anybody at the national or local level that an emergency existed in the loan-repayment program," Herdan says.

Though she feels "very emotionally tied" to the large population of Dominican, Mexican, and other immigrant women she sees, she's finding it harder to meet her monthly loan payments. "Up to this point, I've been making only interest payments on my loans," says Herdan, "but now I have to start paying off the principal. That's difficult, considering I've had no pay raise for the past two-and-a-half years." If she is turned down by the repayment program, her days working among the poor women of Jacobi's Women's Health Center may be numbered.

At a time when access to health care is on everyone's lips, the loss of young professionals like Deb Herdan and Chris Fellenz is certainly a tragedy. And it's a tragedy, experts say, that isn't difficult to avert. "There are a lot of things in this world that money won't fix," says the government's Marilyn Hughes Gaston. "This isn't one of them."


Wayne Guglielmo. Treating the underserved: You call this an incentive?. Medical Economics 2001;2:31.

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