The Medical Education Futures Study Blog

While much of the primary care stimulus funding was cut out in the Senate version of the Stimulus package, it was restored in a modified form in conference and signed into law by President Obama on February 17.  The final law gives a significant boost to community health centers - $500 million for services provided at CHCs and $1.5 billion for construction, renovation, equipment, and health information technology systems - and to the National Health Service Corps - $300 million for recruitment and field activities.  Primary care training funding received a modest boost of $200 million for Title VII and Title VIII of the Public Health Service Act and grants to training programs for equipment.

While increased support for CHCs and the NHSC are critical steps towards increasing care and access to underserved / uninsured communities, the relative levels of funding for these programs in comparison to the funding levels of the primary care training programs indicates a denial of what is and will be a core problem in providing health care to these communities and the nation.  Ultimately the question is - who will provide the health care that is funded through these programs?

CHCs and the NHSC rely heavily on primary care physicians to staff health centers and provide care in underserved areas.  But primary care is in crisis.  Medical students are entering primary care fields at all time low rates.  Yet the National Association of Community Health Centers (NACHC) report health centers currently need over 1,843 primary care providers and if they are to increase their reach, they will need over 15,000 additional primary care providers by 2015.

Solving the primary care problem in the U.S. will require changes in the physician payment system to reduce the income gap between primary care and specialist physicians and changes in the physician practice to maximize evidence based, quality care.  However, changes also need to happen in the primary care pipeline to ensure future medical students will choose to enter primary care fields and be ready to practice in the changing health system.  Many factors have been shown to promote primary care field choices - such as recruitment of students who intend to practice primary care, positive primary care experiences during medical school and strong primary care faculty - all of which are currently supported by Title VII grants.

Change needs to happen across the spectrum of the physician workforce - from practice and payment to recruitment and education.  It’s time to prioritize this issue and recognize the quick fix of funding CHCs and NHSC, without building the primary care workforce, will only lead to a future collapse of the system… to bright shiny health centers without the people to provide the health care within.

The current House Stimulus Package specifies $600 million dollars for strengthening primary care.  The funds are specifically targeted for:

• Training primary care nurses, physicians, and dentists under Title VII and VIII of the Public Health Service Act.
• The provision of health care personnel under the National Health Service Corps.
• The patient navigator program under Title III of the PHS Act.  

The Senate version maintains the $600 million for primary care training without the specificity of where the funds will be directed.

What would $600 million do for primary care?  

Based on FY08 appropriation levels for each of the specified House programs, distributing the stimulus funds based on the current distribution of appropriations and assuming a 2 year distribution of stimulus funding, the package would nearly DOUBLE each programs annual funding if baseline appropriations are maintained at the FY08 funding level.

The stimulus is a start and an opportunity to build these into the robust programs they need to be in order to truly address the problems of primary care, underserved areas, and health care disparities that are persistent and growing problems in the US health care system.

A timely new article by Rittenhouse et al. in the Annals of Family Medicine finds a significant positive association between exposure to Title VII training programs and subsequent physician work in Community Health Centers (CHCs). 

These findings are particularly noteworthy as just four weeks ago, the National Association of Community Health Centers (NACHC) released their report – Access Transformed: Building a Primary Care Workforce for the 21st Century – in which they estimate a current deficit of 1,843 primary care providers in CHCs and a need for an additional 15,585 primary care providers if they are to reach their goal of 30 million patients by 2015.

Since the 1970s, Title VII has supported programs aimed at increasing primary care, underserved areas and minority physicians.  However, funding for these programs has been severely slashed in recent years.  The program was cut in half in 2006.  This year, as in previous years, the President’s FY08 budget all but eliminates the program.  On July 18, the House approved $228 million for Title VII programs – a 24% increase from FY07, but the Senate approved only $188 million for the program on June 21 (AAMC)

As the need for primary care physicians, particularly in underserved areas, grows, it is time to invest in the programs that produce these needed physicians.  And the Rittenhouse article shows us that Title VII programs clearly work.