Provider Retention in High Need Areas. American Recovery and Reinvestment Act (ARRA) and Patient Protection and Affordable Care Act (ACA) funding expansion


The American Recovery and Reinvestment Act (ARRA) was an economic stimulus package to save and create jobs and invest in infrastructure, education, health, and renewable energy. The Act designated $300 million to expand the NHSC, which was intended to add over 4,000 clinicians to the NHSC workforce over a two-year period (ending in February 2011). In total, NHSC saw its workforce rise from 3,017 to 7,713 over this period—an increase of 156 percent (Pathman and Konrad, 2012).

Due to increased funding, the estimated number of people receiving care from NHSC clinicians rose from 4 million to 9 million during this timeframe (Pathman and Konrad, 2012). This study documents the effects of ARRA funds on the NHSC’s workforce size, composition, and location during the first two years of increased funding. During this period, NHSC made several programmatic changes that facilitated expansion. It abolished its HPSA score floor requirement and extended Loan Repayment Program eligibility to include sites located within all HPSAs. In addition, it added a half-time service option and increased maximum loan repayment amounts from $50,000 to $60,000 for an initial 2-year contract. It also revamped its application system and streamlined its assignment process to efficiently facilitate additional enrollment. NHSC interchangeably funded clinicians with both ARRA funds and regular annual appropriations. Pathman and Konrad (2012) document the following changes in enrollment between 2009 and 2011:

  • NHSC LRP clinicians increased from 2,474 in March 2009 to 7,187 in February 2011

  • LRP primary care clinicians increased from 1,449 to 4,095

  • LRP dental care providers increased from 341 to 975

  • LRP mental health clinicians rose from 684 to 2,117

  • NHSC SP awards declined from 543 in March 2009 to 526 in February 2011

Clinician composition also changed significantly during the ARRA funding period. Notably, among primary care clinicians in the Loan Repayment Program, physician enrollment grew substantially less over the two-year period (114 percent) than among nurse practitioners (367 percent), physician assistants (199 percent), and nurse midwives (175 percent). The proportion of physicians among all Loan Repayment Program participants fell from 31.3 percent to 23.1 percent over the two year period. The highest rate of overall growth occurred among nurse practitioners, who increased from 10.1 percent to 16.0 percent of the entire NHSC workforce. Significant growth was also seen among mental health providers—licensed professional counselors increased by 389 percent. Pathman and Konrad, 2012 note that the highest rates of growth were seen in disciplines with lower average income (i.e., licensed professional counselors, dental hygienists, etc.), in which the loan repayment sum constitutes a higher proportion of salary.

The additional ARRA funding did not bring about an immediate change in the urban/rural distribution of the NHSC workforce. Prior to the ARRA period, 44.7 percent of clinicians served in rural areas defined by the Rural Urban Commuting Area (RUCA) classification. In February 2011, 42.0 percent were serving in rural areas. A 2.5 percent decrease was seen in the proportion of NHSC clinicians serving in very small towns (<2,500 population) over this time period. Interestingly, the study found that workforce growth rates varied significantly across states. During the ARRA period, NHSC practitioners rose 291 percent in states with the lowest NHSC clinicians per 100,000 people below poverty rate, compared to a 111 percent growth in states with the highest rates.

Despite growth in NHSC LRP enrollment, the real efficacy of the federal incentives through ARRA will be reflected in the changes in short and long-term retention of NHSC clinicians in underserved areas after the completion of their service obligation period, and whether the program buys more person-years. Another important consideration will be the cost at which more person-years are added. Despite the 2.5 fold growth in total clinicians gained through the supplemental funding, the total workforce still meets less than one-third of the 34,000 physician-need in HPSAs across the United States.

ACA appropriated $1.5 billion in new funding for NHSC over a five-year period beginning in FY 2011. The law contained new provisions to support the recruitment and retention of providers in underserved communities by increasing the value of LRP awards, instituting a half-time service option and allowing for limited teaching and other non-clinical work. This is particularly important now and in the coming years because the rural physician shortage may be exacerbated due to increases in insured patients and pent-up demand for health care, as was seen in Massachusetts after its health care expansion (Massachusetts Medical Society, 2012).

A 2012 study that sought to assess medium and long-term NHSC retention found that clinicians are now remaining in service sites for longer periods of time (Pathman et al., 2012(a)). Many who leave those sites are moving to other sites that are focused on providing care to the underserved. Among NHSC clinicians who finished their final service terms in 1998 and 2005, retention rate at sites focusing on care for the underserved were the highest for physicians and the lowest for physician assistants. In the 2005 cohort, the highest retention was seen for mental health practitioners and the lowest for dentists.21 In 2012, long-term retention rate for dentists and dental hygienists (defined by NHSC as practicing within a HPSA ten years after the completion of the service requirement) was 48.1 percent (NHSC, 2012). The retention rate for mental health and behavioral health care providers (including health service psychologists, licensed clinical social workers, psychiatric nurse specialists, marriage and family therapists, and licensed professional counselors), measured as the percentage of clinicians who remain in a HPSA four years after service obligation completion, was 61.1 percent (NHSC, 2012).

21 It is important to note, however, that the mental/behavioral health disciplines participate only in the Loan Repayment Program.


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