Pathman DE, Goldberg L, Konrad TR, Morgan JC. State Repayment Programs for Health Care Education Loans. JAMA. 2013;310(18):1982-1984. doi:10.1001/jama.2013.281644
Repayment of loans for health care education is a popular incentive among states to attract clinicians to underserved areas. As of 1996, 37 states offered loan repayment programs for primary care clinicians, co-sponsored loan repayment programs with the State Loan Repayment Program of the National Health Service Corps (NHSC), or offered both programs.1 Seven states also offered direct financial incentive programs, which are like loan repayment programs but allow clinicians flexibility in using program funds. In this study, we identified all state loan repayment and direct financial incentive programs for health professionals of all types as of 2010, described changes in program numbers from 2007 to 2010 during the first years of the worldwide recession with tight state budgets, and characterized the disciplines and size of the collective workforce by state.
We identified state programs by searching all available online compendia of programs,2,3 under the terms “loan repayment” and each state’s name, websites of known programs,1 and websites of key recruitment offices by state. Program directors were contacted when program eligibility was uncertain. Eligible programs (1) provided loan repayment or direct financial incentives during the study period to any health professionals (apart from nurses solely below the master’s level) and (2) required clinical service in underserved communities or practices.
We e-mailed questionnaires to all program directors of identified programs, which asked about changes in funding during the 4-year study period and requested tabulation of clinicians by each discipline serving in 2010. Nearly complete survey responses were received from 96 of 99 eligible programs (97%). Missing clinician count data were estimated for 1 or more missing disciplines in 8 programs (9%) using other information from questionnaires (eg, workforce figures for earlier years; n = 5 programs), secondary data (eg, a program report available online; n = 1 program), and a combination of these sources (n = 2 programs).
States offered a total of 93 programs in 2010; 55 were solely state-funded loan repayment programs, 27 were joint state and NHSC loan repayment programs, and 11 were direct financial incentive programs (Table). The number of programs increased from 87 in 2007, with 12 programs created and 6 programs losing all funding (another 6 programs lost then regained funding after 1 or 2 years). All states except Florida, Hawaii, and Mississippi offered at least 1 program during this period.
A total of 3325 clinicians served in state programs as of 2010, with 1288 physicians constituting the single largest discipline (Table). Solely state-funded loan repayment programs fielded the largest workforce with 2284 clinicians, and they supported the highest number and proportion of mental health practitioners among the 3 program types. The number of participating clinicians varied across states from 2 to 488 (Figure).
Loan repayment programs play a prominent role in efforts by states to meet the health workforce needs of underserved communities. Generally, they weathered the first years of the worldwide recession with modest growth in total program numbers. The 1395 primary care clinicians (physicians, physician assistants, nurse practitioners, and certified nurse midwives) serving in solely state-funded loan repayment and direct incentive programs in 2010 was a large increase from the 777 primary care clinicians serving in these programs in 1996.1
Like the NHSC,4 state programs support a diverse workforce. The combined workforce of 3325 primary care, mental health, and dental health clinicians in state programs in 2010 was larger than the 2500 clinicians in the NHSC’s federal loan repayment program in 2008, but about half of the federal program’s 7200 clinicians in 2010 following its rapid expansion under the American Recovery and Reinvestment Act.4,5 For perspective, another 16 125 clinicians are currently needed within Health Professional Shortage Areas.6
Study limitations are that our search may have overlooked a few eligible programs, and clinician participant counts are self-reported by programs and some include our data-derived estimates.
Corresponding Author: Donald E. Pathman, MD, MPH, Cecil G. Sheps Center for Health Services Research, 725 Martin Luther King Blvd, UNC CB#7590, Chapel Hill, NC 27599 (firstname.lastname@example.org).
Author Contributions: Dr Pathman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Pathman, Goldberg, Konrad, Morgan.
Acquisition of data: Pathman, Goldberg.
Analysis and interpretation of data: Pathman, Konrad, Morgan.
Drafting of the manuscript: Pathman.
Critical revision of the manuscript for important intellectual content: Pathman, Goldberg, Konrad, Morgan.
Statistical analysis: Pathman, Konrad.
Obtained funding: Pathman.
Study supervision: Pathman.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Pathman reported serving on the National Advisory Council of the National Health Service Corps from 2009 to 2012; serving as a consultant to the Nebraska Department of Health and Human Services Primary Care Office in 2012; and receiving reimbursement for travel expenses from the National Rural Recruitment and Retention Network. No other disclosures were reported.
Funding/Support: This project was funded through cooperative agreement 5U1CRH03714-04-00 from the US Office of Rural Health Policy.
Role of the Sponsor: The US Office of Rural Health Policy had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.