Who Has Been The Director Of The National Health Service Corps

Summary

The National Wellness Service Corps (NHSC) provides scholarships and loan repayments to health intendance providers in exchange for a period of service in a health professional person shortage area (HPSA). The programme places clinicians at facilities—generally non-for-turn a profit or government-operated—that might otherwise accept difficulties recruiting and retaining providers.

The NHSC is administered past the Health Resources and Services Administration (HRSA), inside the Section of Health and Man Services (HHS). Congress created the NHSC in the Emergency Wellness Personnel Human action of 1970 (P.L. 91-623), and its programs accept been reauthorized and amended several times since then.

The Patient Protection and Affordable Care Human activity of 2010 (ACA; P.L. 111-148) permanently reauthorized the NHSC. Prior to the ACA, the NHSC had been funded with discretionary appropriations. The ACA created a new mandatory funding source for the NHSC—the Community Wellness Centre Fund (CHCF), which was intended to supplement the program's almanac appropriation. However, between FY2012 and FY2017, the CHCF entirely replaced the NHSC's discretionary appropriation. For FY2018, the NHSC received $105 meg from discretionary appropriations in P.Fifty. 115-141 to back up awards to aggrandize and meliorate access to opioid and other substance employ disorder treatment providers. The constabulary also reserves $thirty meg from the $105 million for the new Rural Communities Opioid Response initiative administered by the Federal Office of Rural Health Policy within HRSA. For FY2018, CHCF funding represents 75% of the programme'south appropriation.

The CHCF is fourth dimension-limited. Initially an appropriation from FY2011 through FY2015, the CHCF was subsequently extended in the Medicare Admission and Fleck Reauthorization Human activity of 2015 (MACRA, P.L. 114-10) through FY2017 and then extended for an additional two years (i.e., through FY2019) in the Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-123).

From FY2011 through FY2017, the most recent year of final data available, the NHSC offered more than 39,000 loan repayment agreements and scholarship awards to individuals who have agreed to serve for a minimum of 2 years in a HPSA. In FY2017, the NHSC made 5,711 awards. The number of awards the NHSC makes is simply one component of program size, because non all awardees are currently serving as NHSC providers; some are even so completing their training (e.one thousand., scholarship honour recipients). As such, the NHSC also measures its field strength: the number of NHSC providers who are fulfilling a service obligation in a HPSA in a given year. In FY2017, full NHSC field strength was 10,179. NHSC providers are currently serving in a variety of settings throughout the entire United States and its territories. The majority of NHSC providers serve in outpatient settings, about commonly at federally qualified health centers.

Introduction

The National Health Service Corps (NHSC) is a clinician recruitment and retention program that aims to reduce wellness workforce shortages in underserved areas. The NHSC has iii components: (1) a federal scholarships plan, (2) a federal loan repayment program, and (3) a state-operated loan repayment program. Under each of these programs, health providers receive either scholarships or loan repayments in exchange for a service delivery at an NHSC-approved facility located in a federally designated health professional person shortage area (HPSA, see text box).^one Participants in the state loan repayment programs may also serve in state-designated shortage areas; federal program participants may not. NHSC-canonical facilities are more often than not nonprofit or regime-operated (federal, country, local, and tribal) organizations that provide intendance to patients without regard for the patient'southward power to pay.

Health Professional person Shortage Areas (HPSAs)

HPSAs are areas—rural or urban—with a shortage of primary medical care, dental, or mental health providers. Specific population groups (east.g., populations with unusually high needs for health services, every bit indicated by measures such as the poverty rate and the babe mortality charge per unit) and specific facilities (e.g., a community wellness center, or a facility operated by the Indian Health Service) may also be designated every bit HPSAs.

The HPSA designation is fabricated based on ratios of provider per population; the specified ratio may change, based on the type of HPSA (e.g., primary care or mental health). For example, an area may be designated a primary care HPSA if it has a total-time equivalent main care physician ratio of at least three,500 patients for each primary care physician, or has a ratio of between iii,500 to three,000 patients for each main care physician and has a population with loftier health care needs.

HPSA scores range from 0 to 25 (26 for dental HPSAs), with a college score indicating greater shortages.

Source: Health Resources and Services Administration, Shortage Designation: Wellness Professional person Shortage Areas & Medically Underserved Areas/Populations, at https://bhw.hrsa.gov/ shortage-designation.

The three NHSC programs are managed past the Bureau of Health Workforce (BHW) in the Health Resources and Service Administration (HRSA), an bureau in the Department of Health and Human Services (HHS). The NHSC was created by the Emergency Health Personnel Act of 1970 to provide an adequate supply of trained health providers in federally designated HPSAs.² Since the program's inception, Congress has reauthorized and revised the program several times, with the most recent reauthorization included in the Patient Protection and Affordable Care Human activity (P.Fifty. 111-148, ACA). The ACA permanently reauthorized the NHSC, creating, among other things, a mandatory funding stream for the programme and implementing a part-fourth dimension choice, which allows part-time service in exchange for an extended service commitment.³

This report provides an overview of the NHSC, including the plan's funding, the number and types of providers the programme supports, and the locations where they serve.

Program Overview

The NHSC consists of three programs: (1) a federal scholarships programme, (two) a federal loan repayment programme, and (3) a state-operated loan repayment plan. The federal scholarship plan provides scholarships in exchange for a service commitment at the end of a recipient's education, including whatever grooming required before licensure. The two loan repayment programs provide clinicians with loan repayment in substitution for an firsthand service commitment.^four HRSA administers the federal scholarship and loan repayment programs and provides funds to states. States friction match these funds to operate state loan repayment programs. The largest program is the federal loan repayment program, followed by the country loan repayment plan, so the scholarship program.

The section below describes these three programs. The discussion focuses on programme differences; however, the programs share a number of common elements. Specifically, all three programs require a minimum service delivery of two years in a HPSA.⁵ All are restricted to U.South. citizens or U.S. nationals,⁶ and all provide awards that are exempt from federal income and employment taxes. In addition, all three programs allow physicians,^vii dentists, physician assistants, nurse midwives, and nurse practitioners to participate, but the loan repayment programs also let additional provider types to participate.⁸ The three program types are described below; Tabular array 2 presents data on the number of awards made under each of these programs.

Federal Scholarship Program

The NHSC Scholarship Plan is established in Section 338A of the Public Health Service Act (PHSA).^ix Information technology provides scholarships—including tuition, reasonable pedagogy expenses, and a monthly living stipend—to individuals enrolled full-time in specified education programs at a fully accredited U.S. schoolhouse.¹⁰ Eligible schools/programs include medical schools (allopathic and osteopathic), doctor assistant programs, dental schools, and advance practice nursing schools. Individuals must agree to consummate their training (including residency grooming or required clinical hours, where applicable) in primary intendance.¹¹ For each twelvemonth of scholarship support received (or fractional year after the first year), students must hold to provide an additional twelvemonth of service in a HPSA. For example, if a full-time service scholar receives three years of scholarship support the scholar would owe three years of full-fourth dimension service at an approved facility. The number of school years of NHSC scholarship support received by the scholar may not exceed 4 school years.¹² As such, through the scholarship programme, the maximum required years of total-time service at an approved facility is iv years.

NHSC scholars begin their service commitment upon the completion of training, including whatever advance clinical training needed for licensure (due east.g., primary intendance residency for physicians). Participants must also take obtained a professional license, certificate, or registration before beginning their service commitment. NHSC scholars must fulfill their service commitment on a full-time footing and are required to fulfill their service commitment in a HPSA of "greatest need." Each year HRSA determines the HPSA score indicative of "greatest need." For case, from Oct one, 2016, through September 30, 2017, NHSC scholars must work at NHSC-approved service sites with a HPSA score of 17 or above for their subject field (due east.g., a dental scholar is required to serve in an area with a dental HPSA score above 17).^xiii Individuals participating in the federal loan repayment plan may serve part-time and may serve in areas with lower HPSA scores, just scholars may not. At the end of their service commitment, scholars may apply for continuation awards through the loan repayment plan if they yet accept educational debt remaining and are willing to proceed service at an NHSC-approved facility.

Federal Loan Repayment Program

The NHSC Federal Loan Repayment Program is authorized in PHSA Sections 331(i) and 338B.¹⁴ In improver to the list of providers who may participate in the scholarship program, dental hygienists and behavioral/mental health providers may also receive loan repayment.^fifteen Loan repayment recipients must have a license or certificate needed to do and must be employed or have accepted an offer to be employed at an NHSC-approved work site. Loan repayment is available only for "qualifying educational debt," which ways main, interest, and related expenses of outstanding government and private student loans obtained for undergraduate or graduate education for tuition, forth with reasonable educational and living expenses.^sixteen Federal loan repayors have a two-yr service commitment, which they may fulfill full-time for two years or part-fourth dimension for iv.

The amount of loan repayment received varies based on the HPSA score of the site where the loan repayor is employed. For full-time service at an approved site with a HPSA score of xiv or above, a loan repayor may receive amounts up to $50,000 for an initial ii-year obligation.¹⁷ Individuals serving at a site with a HPSA score of 13 or lower may receive up to $xxx,000 for an initial two years of service. Loan repayment recipients may apply for continuation awards if they have educational debt at the end of their 2-year loan repayment commitment. Continuation awards are awarded in one-year intervals, and individuals may apply for and receive continuation awards equally long as they have qualifying educational debt and remain employed at an NHSC-approved site.

Federal Students to Service (S2S) Loan Repayment Programme

In 2012, HRSA used the authority in PHSA Section 338B¹⁸ to found a new program within the federal loan repayment plan called the Students to Service (S2S) Loan Repayment Plan. The S2S plan provides assistance of upward to $120,000 to medical students (allopathic and osteopathic) in their final year of medical schoolhouse. In render, S2S plan recipients must complete an approved primary intendance residency¹⁹ and undertake their required NHSC service in a HPSA of the greatest need for at least three years (total-time) or six years (one-half-time).^xx S2S repayors may too consummate a one-year fellowship in geriatrics after their primary care residency and before outset their service commitment.²¹

Zika Loan Repayment Programme

In 2016, HRSA fabricated loan repayment awards through a new program funded by the Zika Response and Preparedness Appropriations Human action (P.Fifty. 114-223).²² This program provides upwardly to $70,000 in loan repayment in commutation for a three-year service delivery at NHSC canonical sites in Puerto Rico or other U.Due south. territories affected by Zika.²³ Health professionals eligible for the federal loan repayment programme are also eligible for this programme. Licensed professionals in medical specialties and allied wellness fields who may be able to provide Zika-related care (east.g., physical therapy and certain medical specialties) are also eligible.²⁴

State Loan Repayment Programme

The state loan repayment program is authorized in PHSA Department 338I.²⁵ The program is like to the Federal Loan Repayment Plan, except that (i) it is a matching grant between the state and the NHSC, (two) states may choose to expand or contract the types of clinicians who are eligible to participate in their programme, and (3) states may require more than two years of service in exchange for loan repayment. For instance, states have the option of addressing their unique workforce needs by making boosted types of professionals eligible, such as registered nurses and pharmacists, although neither of these provider types are eligible to participate in the federal loan repayment program. Country loan repayors must provide care in a HPSA in exchange for their laurels, just states determine the approved service sites for their programs. State loan repayment participants must too serve two years equally an initial commitment, but states may require longer minimum service commitments or may vary the service commitment length by provider type. Land loan repayment recipients may fulfill their service commitments on a total- or part-time basis.

NHSC Funding

The amount of total funds that the NHSC receives determines the number of awards that the program can brand. Historically, the NHSC had been exclusively funded as office of HRSA's discretionary cribbing. Still, that is no longer the case, every bit the plan is now funded by the mandatory Customs Health Center Fund (CHCF). The ACA created the CHCF and provided mandatory funding for it over a 5-twelvemonth period (FY2011-FY2015).²⁶ The fund was intended to supplement the NHSC budget; all the same, from FY2012 to FY2017, information technology made up the entirety of the programme'south funding. The CHCF was initially set to expire at the end of FY2015; however, it was extended for 2 years (FY2016 and FY2017) every bit part of the Medicare Admission and Fleck Reauthorization Act of 2015 (MACRA, P.50. 114-x, Scrap is the State Children'due south Health Insurance Plan).²⁷ At the showtime of FY2018, no mandatory funds had been appropriated for the NHSC; however, a temporary extension (P.L. 115-96 ) ultimately provided mandatory funding for the outset two quarters of FY2018, and the Bipartisan Upkeep Act of 2018 (BBA 2018, P.L. 115-123) later provided total-year funding for FY2018 and FY2019. Amounts provided past the CHCF have also been reduced in some years as part of the mandatory spending sequester (pursuant to the Balanced Budget and Emergency Deficit Control Act of 1985, as amended).²⁸ Although the program had not received discretionary appropriations from FY2012 through FY2017, it received $105 million in FY2018 in P.50. 115-141 , with funds directed toward supporting health care providers who provide opioid and other substance apply disorder treatment in HPSAs.

Table i presents funding provided for the plan betwixt FY2011 and FY2019—though amounts for FY2019 are subject to alter. The table besides shows the percentage of funding that comes from discretionary and mandatory sources. For FY2019, the table shows mandatory amounts already appropriated for the plan, simply readers should notation that the FY2019 President's budget requested providing discretionary, rather than mandatory, funding for the program in that year.

Tabular array i. National Wellness Service Corps (NHSC) Funding for FY2011-FY2019

(Dollars in millions)

Funding by Financial Yr	2011	2012	2013	2014	2015	2016	2017	2018	2019
Discretionary	$25 ^a	__	__	__	__	__	__	$105 ^b	__
Mandatory	$290	$295	$300 ^c	$305 ^d	$310 ^eastward	$310 ^f	$310 ^{one thousand}	$310 ^h	$310 ⁱ
Final	$315	$295	$285	$283	$287	$310	$289	$415	TBD
% Mandatory	92%	100%	100%	100%	100%	100%	100%	75%	TBD

Sources: Table prepared by CRS based on information from U.S. Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, Rockville, MD, volumes FY2013 through FY2019.

Notes: Abbreviations in the table notes: ACA = Patient Protection and Affordable Care Act of 2010 (P.Fifty. 111-148, as amended); ARRA = American Recovery and Reinvestment Act of 2009 (P.L. 111-5); BBA 2018 = Bipartisan Budget Deed of 2018 (P.L. 115-123); BBEDCA = Balanced Budget and Emergency Arrears Command Act of 1985( P.L. 112-25); CHCF = Community Health Center Fund; NHSC = National Health Service Corps; MACRA = Medicare Access and Flake Reauthorization Act of 2015 (P.50. 114-10); and Office of Direction and Budget (OMB); TBD = to be determined. Funding levels for FY2011-FY2018 are as enacted or adapted for sequestration, where applicable.

a. ARRA represented a source of discretionary funds that were appropriated to the NHSC in FY2009, just those funds are not considered to be an FY2011 cribbing. Even so, they were reflected in the FY2011 budget. ARRA contributed $57 million (non shown in the tabular array) for federal loan repayments. See Justification of Estimations for Appropriations Committees, Rockville, MD, vol. FY2013, p. 76.

b. P.L. 115-141; $30 one thousand thousand of the amount appropriated ($105 million) is to be fabricated available for a new Rural Communities Opioid Response Initiative administered by the Federal Office of Rural Health Policy in HRSA.

c. ACA appropriated $300 million in mandatory funding for the NHSC to be used in FY2013. Withal, this amount was discipline to the five.1% mandatory spending sequestration, resulting in a total of $284.seven million for FY2013. The sequestration order was issued pursuant to the BBEDCA, every bit amended.

d. ACA appropriated $305 million in mandatory funding for the NHSC to be used in FY2014. However, this amount was subject to the seven.2% mandatory spending sequestration, resulting in $283 million for FY2014.

e. ACA appropriated $310 million in mandatory funding for the NHSC to be used in FY2015. However, this amount was bailiwick to the 7.3% mandatory spending sequestration, resulting in $287 million for FY2015.

f. MACRA extended mandatory funding for the NHSC, as part of the CHCF, for FY2016 and FY2017, at $310 million in mandatory funding each financial year. However, this funding extension was enacted afterward the mandatory spending sequester for FY2016 was calculated by OMB. As a consequence, OMB did not include the FY2016 funding in the sequester calculation, and thus no sequester was ordered for the NHSC funding in FY2016. (Come across OMB Study to Congress on the Joint Commission Reductions for Fiscal Year 2016, Feb 2, 2015, bachelor at https://obamawhitehouse.athenaeum.gov/ sites/ default/ files/ omb/ assets/ legislative_reports/ sequestration/ 2016_jc_sequestration_report_speaker.pdf.). P.L. 114-223 provided $6 1000000 in supplemental NHSC funding for Zika response. Come across discussion in CRS Report R44460, Zika Response Funding: Request and Congressional Action .

one thousand. MACRA appropriated $310 million in mandatory funding for the NHSC to be used in FY2017. However, this amount is subject to the six.9% mandatory spending sequestration, resulting in $289 million.

h. BBA 2018 appropriated $310 one thousand thousand in mandatory funding for the NHSC for each of FY2018 and FY2019. These funds were appropriated later on OMB had calculated the mandatory amounts to be sequestered in these financial years. Equally a result, no sequestration was applied to these mandatory NHSC funds.

i. The FY2019 President's budget requested $310 1000000 in discretionary funding for the NHSC. However, three days before the FY2019 budget was released, P.L. 115-123 appropriated $310 million in mandatory funding for the NHSC in FY2019. The President'southward upkeep requests that NHSC be funded past discretionary spending, instead of mandatory spending, in FY2019. See Letter from Mick Mulvaney, Director Part of Management and Upkeep, to The Honorable Paul D. Ryan, Speaker of the House of Representatives, February 12, 2018, https://world wide web.whitehouse.gov/ wp-content/ uploads/ 2018/ 02/ Addendum-to-the-FY-2019-Budget.pdf.

Program Size

NHSC program size is measured in three means: (1) funding, discussed above; (ii) recruitment, which is the number of awards in different categories; and (3) field strength, which is the number of NHSC clinicians currently fulfilling their service commitments. Recruitment in a given year is generally smaller than the program's field strength because the latter includes loan repayors who are currently fulfilling their service commitments, including those who are fulfilling a second year of their service commitment, and individuals who received scholarships or S2S agreements in earlier years who accept completed their required training and are currently fulfilling their service commitments. The section below discusses recruitment and field strength.

Recruitment

From FY2011 through FY2017, the near contempo year of final information available, the NHSC offered more than than 39,000 loan repayment agreements and scholarship awards to individuals who have agreed to serve for a minimum of ii years in a HPSA. In FY2011, the beginning of the ACA's CHCF, the NHSC received its largest appropriation to date, which increased the number of awards that the NHSC was able to make. The number of awards made has varied since FY2011, with an increment in FY2016, while the number of awards fabricated in FY2017 was more than similar to the number awarded in FY2015.²⁹ Table 2 shows NHSC clinician recruitment activity for the NHSC's active programs, past type of honour, from FY2011 through FY2017.

Table 2. National Health Service Corps (NHSC) Recruitment, FY2011- FY2017

(Past number of awards or agreements [except for states, past number of participants])

Program	FY2011	FY2012	FY2013	FY2014	FY2015	FY2016	FY2017
Federal Loan Repayment Agreements (New)
Federal Loan Repayment Agreements (Continuing)
Total Federal Loan Repayment (New & Continuing)	5,418	4,267	4,505	4,880	four,775	five,190	iv,813
Students to Service Loan Repayment Agreements
Scholarship Awards (New)
Scholarship Awards (Continuing)
Full Scholarship Awards (New & Standing)	262	222	196	197	207	213	188
State Loan Repayment Agreements (Number of Participants)
Full Awards (all types)	vi,074	four,839	5,226	5,620	5,698	6,129	5 ,801

Source: Prepared by CRS, based on information in U.S. Department of Health and Human Services, Health Resources and Services Assistants, Justification of Estimations for Appropriations Committees, FY 201 9, Rockville, Physician, p. 74.

Field Strength

The number of awards the NHSC makes at any point in time is only ane component of programme size, as not all awardees are currently serving as NHSC providers. Specifically, NHSC scholars and S2S program participants are still completing their training. As such, the NHSC also measures its field strength, which is the number of NHSC providers who are fulfilling a service obligation in a HPSA in a given year.³⁰ In FY2017, the about recent yr in which data are available, total NHSC field strength was ten,179.³¹ Field forcefulness is a mensurate of both the NHSC appropriation, which affects the number of awards that tin can exist made, and the relative residual between scholarships and loan repayment, both in the current fiscal year and in the past.³² The NHSC field forcefulness has increased in recent years as the number of awards made has increased (see Figure 1 ). Every bit of April 2018, HRSA data signal that at that place were 8,256 full providers.³³ The majority of these individuals (vii,620) were loan repayors, which reflects the NHSC'southward prioritization of clinicians who will undertake their service commitment immediately in HPSAs.³⁴ In contrast, HRSA makes scholarship awards in an before yr, then the funding investment is not realized for several years, as the scholar completes his or her schooling and required training.

Despite increased field strength, more sites are eligible to receive an NHSC provider than at that place are NHSC providers. Specifically, in April 2018, at that place were 4,605 open up NHSC positions that could not be filled because the NHSC field strength was not sufficient to meet the needs of every NHSC site.³⁵

Figure ane. Trends in National Health Service Corps (NHSC) Field Forcefulness

(FY2011-FY2017)

Source: Prepared past CRS, based on data in U.S. Department of Health and Human Services, Wellness Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY 201 9, Rockville, Md, p. 75.

Note: NHSC field strength is the number of NHSC clinicians or providers who are fulfilling a service obligation in a Health Professional Shortage Expanse (HPSA) in exchange for a scholarship or loan repayment agreement.

Types of NHSC Providers

The NHSC is made upwardly of an increasingly diverse set up of wellness professionals. The composition of the NHSC has inverse over time. In FY2009, physicians accounted for nearly 35% of providers and were the largest group of providers in the NHSC. In dissimilarity, in FY2016, they made up 21%, and behavioral/mental health providers are at present largest provider types.³⁶ Physicians and nurse practitioners are the next largest groups of providers.

In FY2017, the most recent year for which complete data are available, the following three professional person groups made up 73% of the NHSC:

mental and behavioral health providers (30%),³⁷
nurse practitioners, including nurse midwives (23%), and
allopathic and osteopathic physicians (twenty%).³⁸

Figure 2 shows the NHSC'due south workforce by provider type in FY2017, the most contempo yr for which complete data are bachelor.

Figure ii. National Health Service Corps Field Force, by Discipline

(September 2017)

Source: Prepared past CRS, based on data in U.South. Department of Health and Human Services, Wellness Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY 201 9, Rockville, MD, p. 75.

Notes: Total providers = 10,179. Physicians include both allopathic physicians who concord a Doctor of Medicine (Md) degree and osteopathic physicians who concord a Medico of Osteopathic Medicine (DO) caste. "Other Land Loan Repayment Clinicians" may include registered nurses and pharmacists, among others.

Legislative Proposals to Expand NHSC Provider Eligibility

Some individuals and professional person groups take advocated for making additional provider types eligible for the NHSC. For case, legislation in the 115^th Congress (H.R. 1378) would brand chiropractors eligible to participate in the federal scholarship and loan repayment programs, and H.R. 1639 and S. 619 would make physical therapists eligible for the federal loan repayment program.

The Consolidated Appropriations Deed, 2018 (P.L. 115-141), expanded eligibility for the NHSC loan repayment programme to substance use disorder counselors; the police force also increased NHSC funding and specified that this funding be used to support substance use disorder providers. These specifications in the law may avert a number of the potential concerns that exist with other efforts to expand NHSC eligible provider types or sites. Specifically, because the number of applicants applying for awards exceeds the funding available, by efforts to expand provider eligibility have been met with concerns that information technology would increase competition for the program unless there was an increase in appropriations. Moreover, adding new provider types or site blazon does not guarantee that newly eligible clinicians or sites would receive awards, because at that place are no quotas for specific numbers of providers by subject area; however, the changes in the Consolidated Appropriations Act, 2018 (P.50. 115-141), specify that funds be used to support the newly added providers. By and large, NHSC awards are made competitively, with scholarships generally awarded based on participant characteristics (due east.yard., the participant's delivery to primary care practice and the likelihood of remaining in a shortage area after the NHSC service commitment has ended).³⁹ Loan repayment awards are fabricated based on the HPSA score of the site and on the loan repayment program participant'due south characteristics.^xl

Authoritative Authority to Expand NHSC Provider Eligibility

Although legislation has been used to modify eligible disciplines, the HHS Secretary has some potency to add disciplines without new laws being enacted. For case, exchanges among the Secretarial assistant of HHS and the Business firm and Senate Appropriations Committees seem to suggest that Congress recognizes the Secretary's authority to include additional disciplines in the NHSC without congressional action. For example, in 2012, the Senate Appropriations Committee urged the Secretary to offer loan repayments to pharmacists and chiropractors through the NHSC.⁴¹

Despite what appeared at that time to be congressional support for administrative action, in 2013, the Secretarial assistant declined to include pharmacists on the list of eligible NHSC providers. The Secretarial assistant's response to this request from the Senate Appropriations Committee was based on an interpretation that chemist's shop and chiropractor services would exist exterior of the core intent of the NHSC to provide "primary wellness services."⁴²

In 2015, the Senate Appropriations Committee once more raised the issue of the Secretarial assistant'due south authority to add pharmacists, which are sometimes office of main care teams; however, these providers remain ineligible for loan repayment. Like conversations have occurred between HHS and the House Appropriations Commission regarding optometry.⁴³

In each of these instances, HHS has not agreed to expand the programme's eligibility out of concern that doing so would shift the programme away from its traditional focus of providing primary care to underserved populations. HHS also emphasized that the program is currently competitive and that adding new disciplines equally eligible could redirect NHSC funds abroad from already identified clinical shortage areas and add together new ones.⁴⁴ Another concern is that adding new providers may limit the total number of individuals served past the NHSC because the new provider types (east.yard., optometrists and chiropractors) serve a narrower subset of the population than exercise primary care providers.

Despite debates on expanding the clinicians eligible for the NHSC, Congress has, at times, antiseptic the range of eligible providers. For example, the 21^st Century Cures Act, enacted in 2016, clarified that adolescent and child psychiatrists are eligible to participate in the federal loan repayment program.⁴⁵ This law, all the same, did not aggrandize the listing of NHSC providers. Instead, information technology sought to analyze that, within the existing grouping of NHSC-eligible psychiatrists, those who specialize in child and adolescent psychiatry are eligible to participate in the NHSC.

NHSC Provider Locations

NHSC providers may serve at a number of facility types that generally focus on providing outpatient primary care to patients regardless of their ability to pay. In addition, some NHSC provider sites more often than not focus on primary care, such equally community mental health centers, which are more targeted to behavioral health care. As mentioned, these facilities must be located in HPSAs. NHSC eligible sites include⁴⁶

community mental wellness centers,
correctional facilities,
critical admission hospitals,
facilities funded by the Indian Health Service (including those operated by Indian Tribes, Tribal Organizations, and Urban Indian Organizations),
federal wellness centers (i.e., Federally Qualified Health Centers [FQHCs]),
FQHC look-alikes,
gratis clinics,
rural wellness clinics, and
school-based wellness centers.

NHSC providers can be placed at facilities operated by not-for-profit organizations and by government entities (including state, local, tribal, and federally operated facilities). In addition, HRSA requires that NHSC sites are part of a organization of intendance (east.1000., accept after-hours arrangements for patient care); have a documented record of sound fiscal direction; take a history of using NHSC providers appropriately and efficiently; have beneficiaries from Medicare, Medicaid, and CHIP; accept a sliding scale discount schedule; and have general community support for assigning NHSC providers to the facility.⁴⁷

More than one-half of all NHSC providers serve at federally qualified wellness centers (FQHCs), which provide outpatient—by and large primary and behavioral—health care to disadvantaged populations regardless of their ability to pay (run across Figure 3).⁴⁸ NHSC providers likewise increasingly provide care at facilities funded by the Indian Wellness Service, including federal, tribal, and urban Indian health facilities. Equally of August 2017, 492 (5.iv%) providers were fulfilling their service commitment at IHS-funded facilities, an increment from the 421 providers who were placed at IHS facilities as of December 2015.⁴⁹ As mentioned, NHSC providers more often than not fulfill their service commitment in outpatient settings. Yet, some may serve at IHS-funded hospitals, and in recent years, some take fulfilled part of their service delivery (up to 24 hours per week) at critical admission hospitals (CAHs), which are pocket-sized hospitals located in rural areas. Equally of August 2017, 45 NHSC providers were serving at CAHs. HRSA requires that these providers carve up their time between inpatient services at the CAH (up to 24 hours per week) and outpatient services at CAH affiliated-outpatient clinics (not less than 16 hours per week).^l

Figure 3. Facility Types Where NHSC Providers Are Placed

(August 2017)

Source: Email from Part of Legislation, Health Resource and Services Administration, Department of Health and Human Services, Baronial 23, 2017.

Notes: FQHC = Federally Qualified Wellness Center and IHS = Indian Health Service.

NHSC providers are located at HPSAs throughout the United States and its territories (see Figure iv). According to 2016 data, 23% of all NHSC providers served in rural areas.⁵¹

Legislative efforts take too been undertaken to expand the types of sites eligible for NHSC providers, specifically targeting facilities that could provide treatment for individuals with opioid addiction. For example, in the 115^th Congress, Due south. 1453 would make substance use disorder handling facilities eligible provider sites. These facilities provide both outpatient and inpatient services, including medication-assisted handling. Proposals to expand eligible sites may face similar challenges to proposals to expand provider types—namely that the number of sites eligible for NHSC providers exceeds the programme's field strength, and then adding new site types may increment the number of sites and positions that seek NHSC providers only are unable to obtain one.

Provider Retention

The NHSC collects express data on whether NHSC providers remain in HPSAs after fulfilling their service commitments. Available data indicate that less than half (43%) remain at their service site, and nearly 80% exercise in a HPSA ane year afterward their service commitment has ended.⁵² An FY2012 study found that more than half remain in a HPSA 10 years later completing their service. These information are like to what HRSA institute in an FY2000 evaluation of the program.

Author Contact Data

Elayne J. Heisler, Specialist in Health Services ([email address scrubbed], [phone number scrubbed])

Acknowledgments

Bernice Reyes-Akinbileje, former CRS annotator in Wellness Resources and Services, authored a prior study on the National Wellness Service Corps, and Calvin C. DeSouza, CRS geographic information specialist, prepared the map included in this report.

Footnotes

i.	NHSC providers supported by the federal programs must serve at an NHSC-canonical service site; time spent at an unapproved site, fifty-fifty if that site is within a wellness professional shortage surface area (HPSA), does not count toward the clinician'southward service delivery. Run across U.Due south. Department of Health and Man Services, Health Resources and Services Administration, National Wellness Service Corps Loan Repayment Plan, https://nhsc.hrsa.gov/loanrepayment/lrpapplicationguidance.pdf, p. 30.
2.	P.L. 91-623 was enacted on December 31, 1970. The NHSC is authorized in Sections 331-338 of the Public Health Service Human action (PHSA) (42 U.South.C. §254d et. seq.). The federal regulation states the purpose of the loan repayment (42 C.F.R. §62.21) and the scholarship program (42 C.F.R. §62.1).
three.	For additional changes included in the Affordable Care Act, see CRS Report R41278, Public Wellness, Workforce, Quality, and Related Provisions in ACA: Summary and Timeline .
4.	PHSA Section 338G authorizes a 4th plan that would provide a $25,000 loan to an NHSC member in substitution for ii-years of service in a HPSA in private practice. This program has never been implemented.
five.	Some individuals may serve more than 2 years. For example, some may serve function-time in substitution for an extended service commitment and some may extend their commitment upon receiving a continuation award, which entails additional scholarship or loan repayment in exchange for an extended commitment. Run across U.South. Section of Health and Human Services, Health Resource and Services Administration, "National Health Service Corps," http://nhsc.hrsa.gov/ .
six.	U.S. nationals are individuals built-in in certain U.S. territories.
7.	Physicians include individuals who have graduated from allopathic medical schools, which award Medical Doctor (MD) degrees and osteopathic medical schools which grant Doctors of Osteopathy (DO) degrees.
8.	For instance, the federal loan repayment program permits mental and behavioral wellness providers and dental hygienists to participate. The country loan repayment plan allows these additional providers and permits states to designate additional provider types every bit eligible based on the country's workforce needs.
9.	42 UsaC. §254l.
10.	Individuals who attend foreign medical schools are not eligible for the NHSC scholarship plan.
11.	For physicians, this is defined equally family unit medicine, general internal medicine, general pediatrics, obstetrics/gynecology, general psychiatry, and joint programs in a combination of these specialties (e.m., internal medicine/pediatrics). For nurses, this is defined as adult medicine, family medicine, elderliness, primary care pediatrics, psychiatric-mental wellness, or women's health. For dentists, this is divers as general exercise dentistry, advanced education in general dentistry, pediatric dentistry, and public heath dentistry.
12.	U.S. Section of Health and Homo Services, Health Resource and Services Administration, NHSC Scholarship Program, School Yr 2017-2018 Application & Plan Guidance, p. ten, https://nhsc.hrsa.gov/downloads/spapplicationguide.pdf.
13.	Each year, the NHSC uses HPSA scores to make up one's mind where NHSC scholars will be placed. For example, from October 1, 2016, through September thirty, 2017, NHSC scholars must work at NHSC-approved service sites with a HPSA score of 17 or above for their discipline. U.S. Department of Health and Human Services, Wellness Resources and Services Administration, NHSC Scholarship Program, School Year 2017-2018 Awarding & Program Guidance, https://nhsc.hrsa.gov/downloads/spapplicationguide.pdf. Severity of need is adamant by a scoring process that the Secretarial assistant applies to each designated area. A loftier-need HPSA is defined as a HPSA score of 14 or above; the higher the score, the greater the need for an NHSC clinician. U.Southward. Section of Health and Human Services, Wellness Resource and Services Administration, National Health Service Corps Loan Repayment Program, FY2017, January 2017, pp. 16-17.
14.	42 U.S.C. §254d(i), as amended, and 42 U.s.a.C. §254fifty-i, as amended, and respectively.
xv.	A behavioral/mental health worker in the NHSC may be a licensed clinical social worker, licensed professional counselor, health service psychologist, marriage and family therapist, physician (e.g., a psychiatrist, including child and adolescent psychiatrists), nurse practitioner (i.e., a psychiatric nurse specialist), or physician assistant (east.k., mental health and psychiatry). See U.S. Department of Health and Human Services, Health Resources and Services Administration, National Health Service Corps Loan Repayment Programme, FY2017, January 2017, pp. ten-17, https://nhsc.hrsa.gov/loanrepayment/lrpapplicationguidance.pdf.
xvi.	U.S. Department of Wellness and Human Services, Health Resources and Services Administration, National Wellness Service Corps Loan Repayment Program, FY2017, Jan 2017, p. 7, https://nhsc.hrsa.gov/loanrepayment/lrpapplicationguidance.pdf.
17.	Severity of need is adamant by a scoring process that the Secretary applies to each designated area. A high-need HPSA is defined as a HPSA score of fourteen or higher up; the higher the score, the greater the need for an NHSC clinician. U.S. Section of Health and Homo Services, Wellness Resources and Services Assistants, National Health Service Corps Loan Repayment Program, FY2017, January 2017, pp. 16-17.
eighteen.	42 U.S.C. §254lone(a)(two) requires the Secretary to institute an NHSC loan repayment program to recruit health professionals as needed.
19.	Students must complete a residency in family do, general internal medicine, general pediatrics, full general psychiatry, obstetrics-gynecology, internal medicine/family unit do, or internal medicine/pediatrics.
twenty.	In FY2017, for the S2S Plan, sites with HPSAs scores of 14 or above are determined to be of high-need. See U.S. Department of Wellness and Human Services, Wellness Resources and Services Administration, National Health Service Corps, Students to Service Loan Repayment Program, FY2017, https://nhsc.hrsa.gov/loanrepayment/studentstoserviceprogram/applicationguidance.pdf, p. five.
21.	U.Due south. Section of Health and Human Services, Health Resources and Services Administration, National Wellness Service Corps, Students to Service Loan Repayment Program, FY2017, https://nhsc.hrsa.gov/loanrepayment/studentstoserviceprogram/applicationguidance.pdf, pp. half dozen-7.
22.	The Zika Response and Preparedness Appropriations Act (P.L. 114-223) allocated $six meg for loan repayment awards.
23.	For information on awards fabricated nether this program, see U.S. Department of Health and Human Services, Health Resources and Services Administration, "HRSA Awards $7M to Workforce Programs to Combat Zika," press release, July 26, 2017, https://www.hrsa.gov/about/news/press-releases/hrsa-awards-seven-million-to-workforce-programs.html.
24.	The full list of eligible professions for this programme is available at U.S. Department of Health and Human Services, Health Resources and Services Administration, "NHSC Zika Loan Repayment Program," https://nhsc.hrsa.gov/loanrepayment/zikainitiative.html.
25.	PHSA Department 338I(a)(2) (42 U.S.C. §254q–1) authorizes the Secretarial assistant to make grants to states for the NHSC Land Loan Repayment plan provided that a country bureau agrees to administer the program. Within 42 C.F.R. §62.54, the state agencies administering the Country Loan Repayment Programme must comply with regulations to ensure that their health workforce meets requirements for training, placement in medically underserved areas, and comparability to the NHSC Federal Loan Repayment Program, among other things. For program guidance, run across HHS, State Loan Repayment Contacts, http://nhsc.hrsa.gov/loanrepayment/stateloanrepaymentprogram/contacts.html.
26.	The NHSC also received 2 years of funding in FY2009 and FY2010 as role of the American Recovery and Reinvestment Act of 2009. For more information, encounter CRS Study R40181, Selected Health Funding in the American Recovery and Reinvestment Act of 2009 .
27.	CRS Report R43962, The Medicare Access and CHIP Reauthorization Deed of 2015 (MACRA; P.L. 114-10) . CHIP is the State Children's Health Insurance Program (Scrap).
28.	The Counterbalanced Budget and Emergency Arrears Control Act of 1985 was amended by the Budget Command Act of 2011 (BCA, P.Fifty. 112-25) to provide a budget procedure mechanism that would reduce mandatory spending and farther reduce discretionary spending over an extended period. For mandatory spending, the reductions are to occur through "sequestration" in each fiscal year from FY2013 through FY2027. As originally enacted in the BCA, mandatory sequestration was scheduled to run through FY2021, but this catamenia has subsequently been incrementally extended past P.L. 113-67, P.L. 113-82, P.L. 114-74, and P.L. 115-123. CHCF funds have been field of study to sequestration in years in which there was a CHCF cribbing in place at the time the sequester was calculated by the Role of Management and Budget (e.one thousand., CHCF funds were sequestered in FY2013, FY2014, FY2015 and FY2017, but were non sequestered in FY2016, FY2018, or FY2019).
29.	In FY2011, the NHSC received a total of $315 million in appropriated funds, representing a 121.8% increase over the previous year (from $141 meg in FY2010 to $315 million in FY2011) (see "NHSC Funding" in this study).
30.	National Advisory Quango on the National Health Service Corps, Coming together Minutes Summary, HHS, Rockville, MD, 2012, p. 2, https://nhsc.hrsa.gov/corpsexperience/aboutus/nationaladvisorycouncil/meetingsummaries/011912minutes.pdf.
31.	U.Due south. Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY 201 9, Rockville, MD, p. 75. In addition to currently obligated NHSC clinicians, some NHSC alumni may remain every bit providers in a HPSA. These individuals are non included in NHSC field strength data.
32.	Meet section on "NHSC Funding" for a detailed word of NHSC funding sources.
33.	This number is co-ordinate to HRSA data on April 26, 2018. Data available at https://datawarehouse.hrsa.gov/Topics/Nhsc.aspx.
34.	Ibid.
35.	Ibid.
36.	U.S. Section of Health and Human Services, Health Resources and Services Assistants, Justification of Estimates for Appropriations Committees, FY2011, p. 69.
37.	This number is an underestimate because psychiatrists are counted as physicians and advanced do psychiatric nurses are counted as nurse practitioners.
38.	U.S. Department of Wellness and Homo Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY 2018, Rockville, Dr., p. 70. Nurse Practitioners make up twenty% of the NHSC's workforce; 2% of these are nurse-midwives.
39.	U.Due south. Department of Health and Man Services, Wellness Resource and Services Administration, NHSC Scholarship Program, School Yr 2017-2018 Application & Program Guidance, https://nhsc.hrsa.gov/downloads/spapplicationguide.pdf, pp. 7-9.
xl.	U.S. Department of Wellness and Human Services, Wellness Resources and Services Administration, National Health Service Corps Loan Repayment Program, https://nhsc.hrsa.gov/loanrepayment/lrpapplicationguidance.pdf, p. 17.
41.	U.S. Congress, Senate Commission on Appropriations, Subcommittee on Departments of Labor, Health and Human Services, and Education, and Related Agencies, Departments Labor, Health and Homo Services, and Education, and Related Agencies Cribbing Bill, 2012, To Accompany S. 1599 , 112^th Cong., 1^st sess., September 22, 2011, 112-84 (Washington: GPO, 2012), p. 40.
42.	Primary health services are divers equally health services regarding family medicine, internal medicine, pediatrics, obstetrics and gynecology, dentistry, or mental health that are provided by physicians or other health professionals. HHS, HRSA, Justification of Estimates for Appropriations Committees, FY2013, p. 371, http://www.hrsa.gov/about/budget/budgetjustification2013.pdf. In P.L. 107-251, Wellness Care Prophylactic Net Amendments of 2001 (enacted on October 26, 2002), Congress required the Secretary to implement a "Chiropractic/Chemist Demonstration Project" nether Section 338B of the PHSA (or the NHSC'due south Federal Loan Repayment Program). Following a general notice (68 Federal Register 112; 34981; June 11, 2003), the Secretarial assistant implemented the programme just discontinued it afterwards initial demonstrations were completed. Source: CRS email communication HHS, Function of Legislative Affairs, August 2016.
43.	H.Rept. 114-699, Departments of Labor, Wellness and Human Services, and Didactics, and Related Agencies Appropriations Bill, 2017, to accompany H.R. 5926, p. 28.
44.	HHS, HRSA, Justification of Estimates for Appropriations Committees, FY2017, p. 427, http://world wide web.hrsa.gov/most/budget/budgetjustification2017.pdf. In the 2018 Upkeep Justification, HRSA besides declined to broaden the eligible disciplines for the NHSC. Run into Department of Health and Human being Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY 2018, Rockville, Physician, p. 331.
45.	See discussion of Sec. 9023 in CRS Report R44718, The Helping Families in Mental Wellness Crisis Reform Act of 2016 (Division B of P.L. 114-255) .
46.	Under express circumstances, NHSC providers may as well fulfill their service commitment past working in a individual practice in a HPSA. For more information about these facility types, see CRS Report R43937, Federal Health Centers: An Overview for description of wellness centers and Appendix A for description of other NHSC eligible facility types. Indian Health Service facilities are too described in CRS Report R43330, The Indian Health Service (IHS): An Overview .
47.	U.Southward. Department of Health and Human Services, Wellness Resources and Services Administration, National Health Service Corps Written report to Congress For the Year 2016, submitted to the Committee on Wellness, Education, Labor and Pensions, U.Southward. Senate and The Commission on Energy and Commerce, U.South. House of Representatives, Rockville, MD, 2017.
48.	For more than data, meet CRS Study R43937, Federal Health Centers: An Overview .
49.	Email from Function of Legislation, Wellness Resource and Services Administration, Section of Health and Homo Services, Baronial 23, 2017 and U.S. Department of Health and Human Services, Indian Health Service, Justification of Estimations for Appropriations Committees, FY2017, Rockville, Physician, p. 149.
l.	Ibid.
51.	U.S. Department of Health and Human Services, Health Resources and Services Administration, National Health Service Corps Report to Congress For the Year 2016, submitted to the Committee on Health, Educational activity, Labor and Pensions, U.Due south. Senate and the Committee on Energy and Commerce, U.S. House of Representatives, Rockville, MD, 2017. Co-ordinate to the U.S. Census Bureau, xix.3% of the U.S. population live in rural areas; see Usa Census Bureau, "New Census Information Show Differences Between Urban and Rural Populations," press release, December viii, 2016, https://www.census.gov/newsroom/printing-releases/2016/cb16-210.html.
52.	Data in this paragraph are fatigued from U.S. Section of Wellness and Human Services, Health Resources and Services Administration, National Health Service Corps Report to Congress For the Twelvemonth 2016, submitted to the Committee on Health, Education, Labor and Pensions, U.S. Senate and the Commission on Energy and Commerce, U.South. House of Representatives, Rockville, Doc, 2017.