State scholarship, loan forgiveness, and related programs - The unheraldedsafety net

Context In the mid-1980s, states expanded their initiatives of scholarships , loan repayment programs, and similar incentives to recruit primary care p ractitioners into underserved areas. With no national coordination or manda te to publicize these efforts, little is known about these state programs a nd their recent growth. Objectives To identify and describe state programs that provide financial s upport to physicians and midlevel practitioners in exchange for a period of service in underserved area;, and to begin to assess the magnitude of the contributions of these programs to the US health care safety net. Design Cross-sectional, descriptive study of data collected by telephone, m ail questionnaires, and through other available documents, (eg, program bro chures, Web sites). Setting and Participants All state programs operating in 1996 that provided financial support in exchange for service in defined underserved areas to student, resident, and practicing physicians; nurse practitioners; physicia n assistants; and nurse midwives. We excluded local community initiatives a nd programs that received federal support, including that from the National Health Service Corps. Main Outcome Measures Number and types of state support-for-service program s in 1996; trends in program types and numbers since 1990; distribution of programs across states; numbers of participating physicians and other pract itioners in 1996; numbers in state programs relative to federal programs; a nd basic features of state programs. Results In 1996, there were 82 eligible programs operating in 41 states, in cluding 29 loan repayment programs, 29 scholarship programs, 11 loan progra ms, 8 direct financial incentive programs, and Ei resident support programs . Programs more than doubled in number between 1990 (n=39) and 1996 (n=82). In 1996, an estimated 1306 physicians and 370 midlevel practitioners were serving obligations to these state pro-grams, a number comparable with thos e in federal programs. Common features of state programs were a mission to influence the distribution of the health care workforce within their states ' borders, an emphasis on primary care, and reliance on annual state approp riations and other public funding mechanisms. Conclusions In 1996, states fielded an obligated primary care workforce com parable in size to the better-known federal programs. These state programs constitute a major portion of the US health care safety net, and their acti vities should be monitored, coordinated, and evaluated. State programs shou ld not be omitted from listings of safety-net initiatives or overlooked in future plans to further improve health care access.