A Call for National Health Service Corps Investment
As the National Health Service Corps (NHSC) turns 50 years old, the need for a national program designed to care for this nation’s underserved is more apparent than ever. In addition to developing a healthcare workforce that is diverse and culturally responsive throughout the nation, the NHSC is our country’s best, most efficient, and most data-proven clinical care delivery system to ensure well-trained clinicians are paired with communities in need.
The NHSC has national impact – clinicians who are caring for the needy serve in every single state in the country as well as on Indian reservations and in correctional facilities. This is not surprising given the need for physical, mental, and oral health care services in both rural and urban locations in communities throughout the United States. The NHSC is funded by a combination of mandatory and discretional dollars annually, and despite temporary increases in funding, the NHSC is only able to fund approximately 40% of all applications it receives1. This persistent deficit in NHSC funding has resulted in a perpetual shortfall in filled clinician vacancies in underserved communities across the nation.
This situation could be remedied by Congress: allocate – consistently – enough money to fund the Corps for its mission now and the next 50 years. Not only would such an investment help deliver a more robust workforce to the underserved at a time of tremendous need in our nation; it would help accelerate the necessary and long overdue transformation of the healthcare workforce, ensuring not only cultural competency but the racial and ethnic diversity that is a reflection of our peoples and embodies many community and public health principles.
The Association of Clinicians for the Underserved, marking its 25-year anniversary this year, has a 5-pillar plan to connect funding to function. The broad plan is built on perennial key considerations of a strategic plan to enhance the impact of the National Health Service Corps through investment.
The NHSC has a diverse workforce with a long history of service to areas with deep and longstanding geographic and demographic disparities. Despite the even greater impact that the NHSC could have in mitigating disparities while providing clinical care to our nation’s most impoverished and disadvantaged communities, there has never been sufficient funding to meet the need. For example, in the last quarter of 2020, more than 32,000 clinicians were needed to fulfill all Health Professional Shortage Areas (HPSA) designations in consideration to shortages in primary care, dental, and mental health2. Long term, stable funding to address the full scope of need across disciplines can help to ensure millions of Americans will not suffer a lack of access to care, and corresponding health disparities, as a result of clinician shortages.
Nearly 6,450 mental health providers were needed to address HPSA designations at the end of 20202. Expanded eligibility for behavioral health professionals could help address the immediate need in serving the more than 121 million individuals currently living in mental health HPSAs and help to stem the heightened need being seen as a result of the COVID-19 pandemic2. This also addresses structural barriers to success for underserved communities by eliminating the need to have a master’s level behavioral health or counseling degree to provide mental health and counseling services to these communities. This would afford opportunities to highly intelligent and motivated community members who face significant barriers to obtaining master’s degrees. An investment in this regard, as well as scholarships for these providers, would address the structural racism and classism inherent in currently legislated programs.
3. Provide grants to states to engage their K-12 systems, Workforce Investment Councils and AHEC programs to better engage the interest of underrepresented students of color to enter the health care career fields, and to enable more diversification of the healthcare workforce in the future.
Refocusing the healthcare workforce lens on pipeline initiatives starting as early as K-12 can help address persistent access disparities, but perhaps more importantly, help cultivate the diverse clinical workforce of the future. The opportunity to build on the continuum of mentoring, education, training and workforce across existing infrastructure provides a critical opportunity to address vitally needed diversity and move toward true health equity.
4. Expand the number of awards in the NHSC scholarship program to enable more underrepresented students of color to undertake medical, dental or behavioral health training, through a specific funding allotment for such students.
Ensuring greater racial and ethnic diversity of the health care workforce is important. Historically and currently, many racial and ethnic and minority groups are underrepresented within the health profession workforce, a fact which has exacerbated disparities in access and quality of care in these communities3,4,5.
African Americans make up 13% of the U.S. population but comprise only 6.9% of U.S. advanced practice nurses (nurse practitioners and nurse midwives) and 4% of U.S. physicians1. Of actively practicing advanced practice nurses in the US in 2018, 81.8% were white, 7.9% were Asian and 0.2% were American Indian or Alaska Native. Data on practicing physicians in the United States in 2013 showed that 48.9% were white, 11.7% were Asian, 4.4% were Hispanic or Latinx, and 0.4% were American Indian or Alaska Native1. These disparities are most glaring in states such as California where the Latinx population comprises 40% of the population, yet are only 5% of the physician workforce6.
These statistics are in contrast to the workforce of clinicians that represents the NHSC: 13 percent are African American, 10 percent are Latinx, 7 percent are Asian or Pacific Islander, and 2 percent are American Indian or Alaska Native. Specifically reflecting the physician workforce, in 2016, Black or African American physicians represented 17.2 percent of the Corps physicians; Latinx physicians represented 18.2 percent of the Corps physicians1.
5. Re-examine funding for Graduate Medical Education training program slots specifically for NHSC-funded physicians. This would not only expand primary care training slots, but likely increase physician retention in HPSA areas, and fund training programs to produce physicians in specialties needed by the country.
As highlighted in the 2014 Institute of Medicine Report Graduate Medical Education That Meets the Nation’s Health Needs “there is a striking mismatch between the sites where residents are trained compared with the sites where they are likely to spend most of their careers. In the context of…financial disincentive toward non-hospital training, it should be noted that the vast majority of clinical training occurs in teaching hospitals—even for primary care residencies”.7 This perpetuation of a teaching hospital-based training model further undermines the opportunity to attract physicians to practice settings in underserved communities8. This could be examined to align with NHSC/underserved area workforce needs and re-invest monies to reflect the changing workforce needs among medical clinicians (nurse practitioners and physician assistants) as well as behavioral health providers, all of which are in high demand but are not historically part of traditional GME funding.
As we reflect back on the success of the NHSC over the past 50 years and the incredible foundation of skilled clinicians who continue to work in underserved areas years after completing their obligation, we must recommit ourselves to an even more successful path in the future. Inadequate investment in the National Health Service Corps will continue to imperil our nation’s health care system and specifically perpetuate unacceptable disparities in healthcare access to the underserved if we allow it to be so. Instead, let us celebrate this proven track record of addressing workforce shortages, diversity and driving health equity with fierce advocacy, vision and action to ensure an even brighter and more equitable 50 years ahead.
- Olson DP, Nunez F, Overbeck M, et al. The National Health Service Corps at 50: A Legacy of Impact in Partnership with The Association of Clinicians for the Underserved. Journal of Healthcare for the Poor and Underserved, 31 (2): 542-548, May 2020.
- Designated Health Profession Shortage Areas Statistics, Bureau of Health Workforce, Health Services and Resources Administration (HRSA), U.S. Department of Health and Human Services.
- Bach PB, Pham HH, Schrag D, et al. Primary care physicians who treat blacks and whites. N Engl J Med. 2004 Aug 5; 351(6):575-84.
- Moreno G, Walker KO, Morales LS, et al. Do physicians with self-reported non-English fluency practice in linguistically disadvantaged communities? J Gen Intern Med. 2011;26(5):512–517.
- Rabinowitz HK, Diamond JJ, Veloski J, et al. The impact of multiple predictors on generalist physicians’ care of underserved populations. American Journal of Public Health. 2000;90(8):1225.
- Coffman J, Fix M and Ko M. California Health Care Foundation. “California’s Physician Supply and Distribution: Headed for a Drought.” California Health Care Foundation Report.
- Graduate Medical Education That Meets the Nation’s Health Needs. Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services; Institute of Medicine; Eden J, Berwick D, Wilensky G, editors. Washington (DC): National Academies Press (US);2014.
- Goodfellow A, Ulloa JG, Dowling PT, et al. Predictors of Primary Care Physician Practice Location in Underserved Urban and Rural Areas in the United States: A Systematic Literature Review. Acad Med.2016 Sep;91(9): 1313-1321