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Not Directly Related To Obstetrics, But Still Worth Reading --From: Dean Huffman (perinatl@eudoramail.com)Sun Jul 30 09:33:57 2000
July 30, 2000 U.S. Loan Program Squeezing Doctors Sent to Treat the Poor By GREG WINTER When she finished her residency last year, Dr. Regan Andrade received a flurry of job offers near her New York City home. Saddled with $250,000 in student loans, however, she rejected them all. Instead, she signed up for a federal government program that offered a $50,000 bonus to practice in poor communities where doctors are hard to find. So, last fall, Dr. Andrade packed up her three children and took a lower_paying position as a family practitioner in Newport, Wash., a rural logging town of roughly 2,000 people, where the unemployment rate is more than twice the national average. Her new employer was the only hospital in the county __ in fact, the only one for 30 miles around. It had 24 beds. About six months later, settled and working, Dr. Andrade learned that she would not get her grant after all. Without any warning, the government program had run out of money. "If I had any inkling that my loan repayment wasn't going to come through, I wouldn't have come. I couldn't have," Dr. Andrade said. "I'm disgusted. It feels like they're filling these needy areas without having to pay anyone to do it." Multiply her frustration by 700. At least that many doctors, dentists, psychologists and other health professionals have signed up for two_year stints in poor urban and rural areas with the aim of paying back part of their student loans and, like Dr. Andrade, they are being told that the money they expected will not materialize, federal officials say. The National Loan Repayment Program, a $30 million pool of money to attract health workers to remote towns and inner_city neighborhoods, has exhausted its funds after making only a few dozen grants to new applicants this year, threatening the government's ability to get medical professionals where they are needed most. The reason: the Department of Health and Human Services, which runs the program, cut its budget sharply this year to meet other spending requirements set by Congress. With the remaining money, the department for the first time gave grants to people who were still waiting for awards from the previous year. It also gave additional funds to health care providers who had put in their required two years of service, hoping the money would be an incentive for them to stay put, rather than abandon poor communities as soon as their contracts run out. That left newcomers to the program like Dr. Andrade in a financing limbo __ but few say they were ever told. The agency had no policy to warn them that there were prior claims on the money. Officials in Washington said they thought their field offices, scattered around the country, would take on that responsibility. With a record number of professionals vying for the smallest amount of money in years, the budgetary shortfall is the worst in the program's 11_year history. And it is not likely to improve. The 1989 law authorizing the grants is scheduled to expire on Sept. 30 __ and agency officials fear it will not be reauthorized. Few members of Congress are familiar with the program because it has rarely come up in hearings since its creation and because many other health care programs have more effective lobbyists arguing for them. In a year dominated by high_profile health care debates, including a patients' "bill of rights" and Medicare coverage of prescription drugs, the program has received scant attention in Washington. As yet, no member of Congress has stepped forward to sponsor legislation to renew it, and with the end of the year fast approaching, officials wonder if there is still time. "We desperately need a reauthorization," said Dr. Claude Earl Fox, who oversees the program for the department. Dr. Fox said the loan repayment program would still be eligible for one_year extensions at current spending levels, even without explicit reauthorization. But with a growing backlog of applicants, grants under the program would be even harder to obtain, he said. Most of the professionals who were denied financing are already working in overburdened clinics, where they have logged thousands of hours treating indigent and uninsured patients. Some have been on duty for more than a year, expecting their grants would arrive at any time. Most say they did not learn that the money would not come through until several months after they had accepted positions that typically pay less than jobs in private practice or at health maintenance organizations. Some have still not been told, despite calling repeatedly to ask when their money would arrive, since the department missed many of its own deadlines for letting providers know their status. "That's what really upsets me," said Dr. Roxanne Collins, a dentist who has worked at Las Clínicas del Norte El Rito in rural New Mexico since March of last year. "They didn't even bother to tell me that they didn't have the funds." After graduating from the Goldman School of Dental Medicine at Boston University in 1998 with $150,000 in student debt, Dr. Collins says she passed up positions paying $40,000 more than what she now earns in favor of loan repayment. It seemed like a good idea at the time, she says, since her preference has always been to work with Spanish_speaking immigrants. But she says her salary alone is barely enough to make her $2,000 monthly loan payments. "If I had known I wouldn't get a grant, I wouldn't even have bothered," she said. A few of the doctors have begun investigating whether they have any legal recourse to force the government to come up with the money for the loan payments. But government officials say they have not reneged on any written commitment, since the medical professionals signed employment contracts with the clinics. Grappling with the budget shortage, the department saved its new grants for areas with the greatest need. And so it unexpectedly eliminated more than 100 clinics that had long been approved for loan repayment from its list of eligible sites. I feel like I'm playing a game, but they keep changing the rules on me," said Mary Joan L. Murphy, a nurse practitioner in New York who says her clinic was deemed ineligible after she worked there for more than a year. The unpredictability of the process has alarmed officials of community health centers, which are the only primary health care option for many of the nation's poor and uninsured, a population with particularly acute medical needs. Recruiting trained specialists is a daunting task for the centers, and many worry that the scarcity of new grants will greatly worsen staffing shortages, especially at clinics in rural areas. "We use loan repayment as our primary recruiting tool," said Stephen D. Wilhide, chairman of the National Rural Health Association committee that is leading the effort to lobby Congress for reauthorization. "We could simply not get enough doctors without it." The same is true for many inner_city clinics that have recently hired physicians with the promise of loan repayment, unaware that a mere handful would be approved. Unless grants are virtually guaranteed in the coming years, many clinics fear they will no longer be able to bring new medical professionals on board. "This has definitely affected our credibility," said Vicki L. Marie, a recruiter for Northeast Ohio Neighborhood Services, a chain of clinics serving Cleveland's African_American population. Last year, the health service hired two physicians with the expectation that they would get their loans repaid, just as it has in past years before grants were in such short supply. "Now, we're just sitting here hoping that these providers don't leave and go to a more lucrative practice," she said. But in fact, compelled to pay off their loans, and in some cases feeling betrayed, some clinic staffers say they are already looking for better_paying jobs elsewhere. Three years ago, Colleen Wall_Hoeben, a clinical psychologist, moved to the windy buttes of Wyoming in order to get money to repay loans. The job she accepted, she said, paid roughly half the salary of $75,000 to $100,000 that awaited her at a Salt Lake City private practice, but it would enable her to erase her debt. Or so she thought. In May, Dr. Wall_Hoeben received a letter informing her that the program had run out of money, a formal notice that many have yet to receive. "It doesn't make sense to stay, earning at that low of a level, with the hope of someday getting the loan repayment," Dr. Wall_Hoeben said. "It's a lot of hard work, and there's more money to be made at other places." Faced with the prospect of losing some of their most qualified staff members, some health centers are scrambling to raise money to compensate them for the loss in federal subsidies. But community clinics' fund_raising capabilities are limited, since most rely on government grants to keep their doors open. Nor can most clinics tap into patient fees to pay for higher salaries. Required by law to serve anyone in need of treatment, most government_funded health centers see a disproportionate number of uninsured patients who are asked to pay what they can. Other patients are mostly covered by Medicare and Medicaid, two programs that had their reimbursement rates cut under the Balanced Budget Act of 1997. Besieged by calls from cash_short clinics, the National Association of Community Health Centers began lobbying members of Congress this spring, pushing for an expansion of the loan repayment program. After meeting with representative from both parties, the association secured a $4 million increase in the House budget for the program, but no growth in the levels proposed by the Clinton administration or by the Senate. Association officials are fairly confident that the increase in the House, though small, will make it into the final budget for the program. "That's peanuts; that's not enough," said Representative Carolyn Maloney, a New York Democrat who began looking into the program last month. Representative Maloney said it was un likely Congress would consider releasing additional money through an emergency measure, as it did in June to support troops in Kosovo, combat drugs in Columbia and provide relief for wildfire and flood victims. With that in mind, community health centers began an effort to get the program's legislation reauthorized, a rare opportunity to showcase the importance of loan repayment and press for more money. But the coalition was riddled with internal conflicts, and it quickly disbanded after dividing over how much money should be designated for different medial specialties. "These squabbles have frozen any action on the Hill," lamented Dan Hawkins, policy director of the National Association of Community Health Centers. Health department officials are equally frustrated that the reauthorization effort appears to have been shelved. Under current law, all cash awards to health workers are taxable, a disincentive the program has overcome by adding money to each grant. For years, department officials have sought to rewrite the law to make the grants tax_free, a change that would free money to pay for 200 more clinicians each year. Still, the department says it would have to place at least 20,000 clinicians, compared with the 1,900 it now supports, to assure poor communities adequate access to health care. "The bottom line is, the need is appalling in comparison to the resources available," Dr. Fox said. Copyright 2000 The New York Times Company
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