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National Health Service Corps: Background, Funding, and Programs

Changes from April 22, 2015 to May 17, 2016

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National Health Service Corps: ChangesBackground and Trends in Funding and Impact on Recruitment

April 22, 2015May 17, 2016 (R43920)
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Summary

The National Health Service Corps (NHSC) recruits and places trained individuals in underserved communities to provide health care services at approved sites. In exchange for a two-year service commitment in federally designated health professional shortage areas (HPSAs), individuals receive scholarships or loan repayments. NHSC clinicians may fulfill their service commitment at approved Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes, Rural Health Clinics, Critical Access Hospitals, and other approved sites.

The primary objective of the NHSC is to increase the availability of primary care services to underserved populations. The NHSC offers scholarships, loan repayments, and loan forgiveness to individuals in selected health professions. In FY2015, an estimated 8,495 NHSC clinicians will provide medical, dental, and other health care services to 8.9 million individuals in underserved communities. Also, in FY2015, the NHSC will award an estimated 2,272 new loan repayment agreements; 1,629 continuing loan repayment agreements; 100 student to service loan repayments; 464 state loan repayments; 163 new scholarships; and 14 continuing scholarships to individuals in various health professions.

The NHSC was established in the Emergency Health Personnel Act of 1970 (P.L. 91-623), and it has been amended and reauthorized several times since its inception. Most recently, Congress revised the NHSC in the Patient Protection and Affordable Care Act of 2010 (ACA; P.L. 111-148) by amending statutory authorities associated with part-time service, teaching credits toward service obligations, and exclusions from an individual's gross income for those payments from state loan repayment or loan forgiveness programs that seek to increase health care access in HPSAs or other designated underserved areas. The NHSC is based within the Health Resources and Services Administration (HRSA), an agency in the Department of Health and Human Services (HHS).

The ACA created a new Community Health Center Fund (CHCF) and required that a total of $1.5 billion in mandatory CHCF appropriations be transferred to the NHSC over the course of FY2011 through FY2015. Prior to the ACA, Congress had appropriated funds for the NHSC solely through the discretionary appropriations process for the Departments of Labor, Health and Human Services, and Education, and Related Agencies (Labor-HHS-ED). Since FY2012, in the absence of discretionary funding, the CHCF has been the NHSC's only funding source. On April 16, 2015, the President signed P.L. 114-10, Medicare Access and CHIP Reauthorization Act (MACRA), which amends the ACA to extend mandatory funding for the NHSC from FY2015 through FY2017. Total NHSC funding, regardless of the source, affects the size of the NHSC health workforce that is available to provide health services in underserved areas. This report briefly summarizes the NHSC programs, describes recent trends in clinician service, reviews funding trends for FY2009 through FY2015, and includes data from the President's FY2016 budget.

National Health Service Corps: Changes in Funding and Impact on Recruitment

Introduction

The National Health Service Corps (NHSC) is a clinician recruitment and retention program that Congress created to reduce health workforce shortages in underserved areas. The NHSC recruits qualified individuals who agree to serve in federally designated health professional shortage areas1 in exchange for scholarship awards and loan repayment agreements. NHSC scholars must study in a program leading to a degree in medicine (allopathic or osteopathic); a degree in dentistry; or in a program for physician assistants, nurse-midwifery, or nurse practitioners. On the other hand, NHSC loan repayers must be trained and licensed to provide direct patient care as allopathic or osteopathic physicians, physician assistants, nurse practitioners, certified nurse midwives, dentists, dental hygienists, or behavioral/mental health providers. All NHSC scholars and loan repayers must agree to serve at an NHSC-approved facility that is located in a health professional shortage area (HPSA), for a minimum of two years.2

The Emergency Health Personnel Act of 19703 created the NHSC to eliminate health workforce shortages in federally designated locations. Over the 45 years that the NHSC has existed, Congress has reauthorized and revised the program several times, and most recently permanently authorized and amended the NHSC in the Patient Protection and Affordable Care Act of 2010 (ACA; P.L. 111-148).4 The ACA also established the Community Health Center Fund (CHCF),5 which provides mandatory appropriations6 for the NHSC and the Federal Health Center Program.7 The ACA modified the law to

  • require that a total of $1.5 billion in mandatory CHCF funding be transferred to the NHSC over the course of FY2011 through FY2015;
  • implement a part-time option from which NHSC clinicians may choose to fulfill their service commitments;
  • excludes from an individual's gross income any amount that an individual receives under any state loan repayment or loan forgiveness programs that aim to increase health care access in HPSAs or other designated underserved areas;
  • permit NHSC clinicians to count time spent teaching toward the fulfillment of their NHSC service commitment; and
  • require the Secretary to redefine how HPSAs are designated.

The NHSC is based in the Bureau of Health Workforce (BHW) within for a minimum of two years. The federal NHSC program awards scholarships and loan repayments, and state programs award loan repayments only.

The NHSC awards scholarships to individuals studying in a program leading to a degree in medicine (allopathic or osteopathic)3 or a degree in dentistry, or in a program that trains physician assistants, nurse-midwives, or nurse practitioners. NHSC makes loan repayment agreements available to clinicians in the professions that the scholarship program permits and expands the list of clinicians to include dental hygienists and behavioral/mental health (BMH) providers.4 Further, the state loan repayment program includes all the NHSC approved scholarship and loan repayment providers and expands its list to clinicians who are trained in other disciplines (such as pharmacy or optometry). All NHSC scholars and loan repayers (federal and state) must agree to serve for a minimum of two years5 at an NHSC-approved facility that is located in a HPSA.6

The NHSC's programs are managed within the Bureau of Health Workforce (BHW) in the Health Resources and Service Administration (HRSA), an agency in the Department of Health and Human Services (HHS). The NHSC is an integral part of the health safety net, asBecause its clinicians are employed at facilities that provide care to the underserved, such as Federal Health Centers7 and Rural Health Clinics (RHCs), the NHSC is an integral part of the health safety net.8 Brief History

The purpose of the NHSC program, which was created in the Emergency Health Personnel Act of 1970,9 is to provide an adequate supply of trained health providers in federally designated locations where clinicians are in short supply and access to care is limited. Over the 45 years of the NHSC's existence, Congress has reauthorized and revised the program several times. In 2010, Congress permanently authorized the NHSC in the Patient Protection and Affordable Care Act of 2010 (ACA; P.L. 111-148, as amended).10 In addition, the ACA

  • established the Community Health Center Fund (CHCF),11 which authorized mandatory appropriations12 for the NHSC (and the Federal Health Center Program)13 from FY2011 through FY2017;14
  • required the Secretary to redefine how HPSAs and Medically Underserved Areas/Populations are designated;15
  • implemented a part-time option from which NHSC clinicians may choose to fulfill their service commitments;
  • authorized a policy that excludes from taxed income the money that an individual receives from NHSC and similar loan repayment and scholarship programs that are designed to increase health care access in HPSAs or other designated underserved areas; and
  • authorized a policy that permits NHSC clinicians to count time spent teaching at teaching health centers16 toward the fulfillment of their NHSC service commitment.

This report summarizes the NHSC's recruitment and retention programs, salient trends, and the NHSC's funding history from FY2010 through FY2016, and the President's FY2017 budget request.

Recruitment and Retention Programs

Various sections in Title III of the Public Health Service Act (PHSA) authorize clinician recruitment and retention programs as part of the NHSC. NHSC participants must agree to a period of service in a federally designated HPSA in exchange for scholarships and/or loan repayment. If NHSC scholars and loan repayers are in good standing and eligible for additional awards, they may receive continuation awards, thereby extending the clinician's length of service in a HPSA.

The NHSC supports programs at the federal and state levels. The federal program supports loan repayments and scholarships, with the loan repayment program making the majority of all federal awards. States participating in the NHSC receive federal funding in the form of matching funds.17 Nearly all NHSC programs offer continuation agreements to qualified individuals, with the objective of increasing the NHSC clinician field strength and length of time served in a HPSA. Each state has the authority to make awards for loan repayments according to its needs, but in a manner that is consistent with federal regulation.18

Scholarship Program PHSA and Rural Health Clinics (RHCs).8 All NHSC clinicians complete service requirements at NHSC-approved facilities, with most serving at federal health centers or at RHCs.9

From FY1972 through FY2011, the NHSC received discretionary funding through the annual Labor-HHS-ED appropriations bills.10 Beginning in FY2011, the mandatory CHCF began to transfer funds to supplement the NHSC discretionary appropriation. However, in FY2012 and subsequent years, no discretionary funds were appropriated to the NHSC. Instead, the mandatory CHCF has been the sole source of NHSC funding. This funding pattern is a potential concern because legislative authority and appropriations for the CHCF will expire at the end of September 2015. The NHSC's reliance on the CHCF is raising concern among program advocates who represent health professional consortia, institutions, and underserved populations that benefit from, or are associated with, the NHSC's scholarship and loan repayment programs.11

On February 2, 2015, the Obama Administration released its FY2016 budget request, which would provide $810 million for the NHSC through a combination of discretionary funds ($287 million) and new mandatory funds ($523 million). This budget request represents an overall increase of $523 million (+182.2%) from the FY2015 operating level of $287 million.12

On April 16, 2015, the President signed the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10), which amends Section 10503(b)(2)(E) of the ACA to extend mandatory funding for the NHSC from FY2015 through FY2017.

This report describes the NHSC's recruitment and retention programs, presents trends in field strength, tracks funding history for FY2009 through FY2015, and includes details on the President's FY2016 budget request.

Recruitment and Retention Programs

Various sections of the Public Health Service Act (PHSA) authorize NHSC programs for clinician recruitment and retention. The PHSA also authorizes financial assistance in the form of scholarships and loan repayment. NHSC participants must agree to a period of service in a federally designated health professional shortage (or underserved) area in exchange for scholarships and/or loan repayment. If NHSC participants are scholars in good standing and eligible for additional awards, they may receive scholarship continuations; likewise, eligible loan repayers may receive loan repayment continuations. Nearly all NHSC programs offer continuation agreements to qualified individuals, with the objective of increasing the NHSC clinician field strength and length of time served in an underserved area.

The PHSA establishes authority for the following NHSC programs or activities. Section 338A establishes the NHSC Scholarship Program, which recruits students who are enrolled in medical school, physician assistant school, dental school, or advance practice nursing school. Qualified individuals may receive financial support through scholarships, which include tuition, reasonable education expenses, and a monthly living stipend. Students must be enrolled in a fully accredited trainingtraining program, and they may receive up to four years of benefits in exchange for a service commitment. With each full year (or partial year) of support after the first year, the student must agree to provide an additional year of service in an underserved area.13

Section 338B establishesa HPSA. For example, if a qualified student gets three years of scholarship support they would owe six years of full-time service.19 Federal Loan Repayment Program PHSA Sections 338B and 331(i)20 establish the Federal Loan Repayment Program, which recruitsis designed to recruit licensed professionals, including physicians, physician assistants, dentists, dental hygienists, advanced practice nurses, and mental/behavioralbehavioral/mental health workers.21 These professionals must be employed or have accepted an offer to be employed at an NHSC-approved work site. Qualified individuals may receive loan repayment agreements in amounts up to $50,000 (for a full-time service commitment) and up to $30,000 (for a part-time service commitment), depending on the severity of need for their selected work site.14

Section 338B authorizes the Secretary of HHS to establish the NHSC Students to Service (S2S) Loan Repayment Program, which recruits medical students in their last year of medical school to apply for loan repayment assistance of up to $120,000 in return for completing a primary care residency and working in a HPSA of the greatest need for at least three years.15

Federal loan repayers have a choice of service options based on full- or part-time service.

For full-time service, an individual may receive amounts up to $50,000 for an initial two-year obligation, when serving at an NHSC-approved site with a HPSA score of 14 or above.22 Also, for full-time service, an individual who serves at an NHSC service site with a HPSA score of 13 or lower is eligible to receive up to $30,000 for an initial two years of service.

Students to Service (S2S) Loan Repayment Program

PHSA Section 338B23 establishes authority for the Secretary of HHS to create the Students to Service (S2S) Loan Repayment Program, which began in 2012. The S2S program provides assistance of up to $120,000 to medical students (allopathic and osteopathic) in their final year of medical school. In return for the loan repayment, the S2S loan repayer must complete an approved primary care residency24 in a HPSA of the greatest need for at least three years (full time) or six years (half time).25 Alternatively, the S2S loan repayer may complete post-graduate training as an intern or geriatrics fellow in an approved specialty for a period of one year.26

State Loan Repayment Program PHSA Section 338I authorizes the State Loan Repayment Program. The State Loan Repayment Program is similar to the Federal Loan Repayment Program, except that (1) it is a matching grant between the state and the NHSC, and (2) states have some flexibility in establishing loan repayment amounts for their clinicians, and for meeting their self-identified health care workforce needs. States may choose to offer continuation agreements to qualified professionals from the various health professions. Registered nurses and pharmacists are the only health professionals who are not included in the Federal Loan Repayment Program but are eligible for the State Loan Repayment Program. If states choose to offer loan repayments to other disciplines not recognized by the Federal Loan Repayment Program, such as optometrists and chiropractors, they may not fund them with NHSC federal or state matching funds.16 The statute and federal regulation provide guidance to State Loan Repayment Programs on selecting health professionals.17

Table 1 shows NHSC clinician recruitment activity for the NHSC's active programs, by type of award, from FY2011 through FY2014, and the FY2015 estimate.

Table 1. NHSC Recruitment, FY2011-FY2015 (Est.)

can choose to expand or contract the number of clinicians in their program. States have the option of addressing their unique workforce needs by choosing from additional types of professionals, such as registered nurses and pharmacists (who are ineligible to participate in the federal loan repayment program). Federal statute, regulation, and a program document provide additional guidance for clinician selection in the State Loan Repayment Program.27 Special Loans for Former Corps Members to Enter Private Practice

PHSA Section 338G establishes an additional option for NHSC participants. This provision authorizes the Secretary to make a single loan to an NHSC member on the condition that the member must serve as a full-time private practice provider in a HPSA for a minimum of two years, in exchange for a loan in amounts up to $25,000. This option has never been implemented.28

Trends in Recruitment

Within the past five years, from FY2011 through FY2015, the NHSC offered more than 27,000 loan repayment agreements and scholarship awards to individuals who have agreed to serve for a minimum of two years in a HPSA. The following is a summary of those awards:

  • 23,854 federal loan repayment agreements (new and continuing);
  • 1,084 scholarship awards (new and continuing);
  • 322 students to service agreements (new only); and
  • 2,206 state loan repayment awards (defined by each state).

In FY2013 through FY2016, the NHSC gave more than 96% of its awards to federal loan repayers, and the remaining 4% to scholars.29

In FY2011, the NHSC awarded more than 4,000 new federal loan repayments, the largest number of new loan repayments in a single year due to a larger program appropriation.30 Table 1 shows NHSC clinician recruitment activity for the NHSC's active programs, by type of award, from FY2011 through FY2016, and the President's budget request for FY2017. Table 1. NHSC Recruitment, FY2011-FY2016, and the President's FY2017 Budget Request

By Number of Awards or Agreements (Except for States, by Number of Participants)

Program

FY2011

FY2012

FY2013

FY2014

FY2015 Estimate

Scholarship Awards (New)

253

FY2016

FY2017 Pres. Req.
Federal Programs

Federal Loan Repayment Agreements (New)
4,113

2,342

2,106

2,775
212

2,943
180

2,654
190

2,442
163

Scholarship AwardsFederal Loan Repayment Agreements (Continuing)

1,305

9
1,925

2,399

2,105
10

1,841
16

1,732
7

2,006
14

Total Federal Loan Repayment (New & Continuing)

5,418

4,267

4,505

4,880

4,784

4,386

4,448

Scholarship Awards (New)

253

212

180Federal Loan Repayment Agreements (New)
4,113

190
2,342

196
2,106

165

2,775

146
2,272

Federal Loan Repayment AgreementsScholarship Awards (Continuing)

9

1,30510

16
1,925

7
2,399

11
2,105

16

1,629
13

Total Scholarship Awards (New & Continuing)

262

222

196

197

207

181

159

Students to Service Loan Repayment Agreements

__

69

78

79

100

 

 96

117

167

President's FY2017 Proposed Mental Health Opioid Initiative Loan Repayment

 

878

President's FY2017 Proposed Behavioral Health Initiative Loan Repayment

 

351

State Program

State Loan Repayment Agreements (Number of Participants)

394

281

447

464

620

464
433

500

Source: Prepared by CRS, based on data in Department of Health and Human Services, Health Resources and Services Administration, JustificationFY2016 Justification of Estimations for Appropriations Committees, FY2016, Rockville, MD, pp. 81-82; in FY2017 respectively, pp. 82-83pp. 81-82.

Note: SLRP participants are selected by, and contract with, the state grantees.

PHSA Section 338G establishes an additional option for NHSC participants, but it has never been implemented.18 The provision for Special Loans for Former Corps Members to Enter Private Practice authorizes the Secretary to make one loan to an NHSC member. The NHSC member must agree to serve as a full-time private practice provider in a federally designated health professional shortage area for a minimum of two years, and may apply for loans in amounts up to $25,000.

Field Strength

NHSC field strength represents the number of NHSC clinicians that are fulfilling service obligations in return for scholarships and loan repayment agreements. Yesterday's recruits—scholars and loan repayers—comprise today's field strength. As of September 30, 2014, a total of 9,242 NHSC clinicians comprised the NHSC's field strength.19 From FY2009 through FY2011, NHSC field strength more than doubled, rising from 4,808 clinicians to 10,279. A decrease in field strength, relative to the FY2011 level, occurred in FY2012, with field strength standing at 9,908 clinicians in FY2012 and dropping further to 8,899 in FY2013. FY2015 field strength is an estimated 8,495, or 747 clinicians (-8%) less than the previous year.

Field strength reflects all the different types of disciplines that deliver health care services to underserved populations. Mental/behavioral health professionals and physicians (allopathic and osteopathic) make up more than half of the NHSC's field strength identifies these and other clinicians by discipline. Beginning in 2015, "HRSA is directed to evaluate the establishment of a demonstration project within the NHSC in which optometrists are recognized as primary health services providers for purposes of the Loan Repayment Program."20

Figure 1. NHSC Disciplines as of September 2014

Source: Prepared by CRS, based on data in Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY2016, Rockville, MD, p. 75. Percentages may not sum to 100% due to rounding. "Other State Loan Repayment Clinicians" make up less than half of 1% of NHSC clinicians, and these represent various health professions.

Notes: Allopathic physicians hold a Doctor of Medicine (M.D.) degree; osteopathic physicians hold a Doctor of Osteopathic Medicine (D.O.) degree. "Other State Loan Repayment Clinicians" may include registered nurses and pharmacists.

Figure 2 shows trends associated with NHSC funding amounts and funding sources for FY2009 through FY2015. Between FY2009 and FY2012, cumulative NHSC field strength increased as discretionary funding increased. However, cumulative field strength decreased when discretionary funding decreased, even though CHCF funding increased.

Figure 2. Trends in NHSC Field Strength,
FY2009-FY2015 (Est.)

By Budget Source: Discretionary, ARRA Supplement, and Mandatory Supplement

Source: Prepared by CRS, based on data in Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY2016, Rockville, MD, p. 82.

Notes: The NHSC enters into multiyear agreements with its participants, resulting in funding overlaps. Base Field Strength represents clinicians who are supported through discretionary funds. ARRA Field Strength represents clinicians who are supported through "ARRA funds," which were appropriated in the American Recovery and Reinvestment Act of 2009 (ARRA; P.L. 111-5). Mandatory Field Strength represents clinicians who received appropriations through the mandatory Community Health Center Fund (CHCF), which was authorized in the Affordable Care Act (ACA) (P.L. 111-148).

Funding

Before the enactment of the ACA (in March 2010), discretionary funding provided through the appropriations bill for the Departments of Labor, Health and Human Services, and Education, and Related Agencies (L-HHS-ED) was the primary source of NHSC funding. The mandatory CHCF did not exist. In FY2009, the American Recovery and Reinvestment Act of 2009 (ARRA; P.L. 111-5) provided a one-time $300 million supplemental appropriation to the NHSC, and this supplement enabled the NHSC to increase its clinical recruitment and retention efforts over the next five years into FY2014 (of note, a number of NHSC scholars and loan repayers who received ARRA funding in 2009 will complete their period of service in underserved areas during FY2015 and FY2016).

In FY2010, the ACA was enacted. The ACA directly appropriated mandatory funding to the CHCF for each of FY2011-FY2015 and required that specific amounts—totaling $1.5 billion (pre-sequester) over five years—be transferred annually from the CHCF to the NHSC.21 The ACA funding built on the clinical recruitment and retention efforts established by ARRA, thereby circumventing large reductions in NHSC field strength.22

In FY2011, ACA funding from the CHCF combined with annual discretionary appropriations provided a total of $315 million for the NHSC, resulting in a $174 million (+123% increase) over the previous year. In FY2011, the NHSC received a combination of discretionary L-HHS-ED appropriations and directly appropriated (or "pre-appropriated") mandatory funds from the CHCF.23 However, the NHSC received no discretionary appropriations in FY2012 through FY2015 and has instead been funded solely by mandatory funding transferred from the CHCF. In each of FY2013 through FY2015, these mandatory funds have been subject to reductions due to sequestration required by the Budget Control Act of 2011 (BCA), as amended.24 Mandatory ACA funding for the NHSC was scheduled to expire on September 30, 2015, but the Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10) extends ACA mandatory funding for the NHSC from FY2015 through FY2017.25

President's FY2016 Budget Request

On February 2, 2015, the Obama Administration released its FY2016 budget. The President's FY2016 budget request includes a total of $810 million for the NHSC, which would increase the total NHSC budget nearly threefold over the previous year. This request consists of $287 million in discretionary funds and $523 million in new mandatory funds in FY2016. In addition, the President's budget proposes new mandatory funding of $523 million annually through FY2020.26

Table 2 presents NHSC funding from FY2009 through FY2015 along with the President's FY2016 budget request.

Table 2. NHSC Funding, FY2009-FY2015, and the President's FY2016 Budget Request

(Dollars in millions)

Funding

FY2009

FY2009 ARRA

FY2010

FY2011

FY2012

FY2013

FY2014

FY2015

FY2016 Pres. Req.a

Discretionary

$135

$300

$141

$25

__

__

__

__

$287

CHCF Mandatory

__

__

__

$290

$295

$285b

$283c

$287d

$310e

New Mandatory

  

 

 

 

 

 

 

 

$523

Total

$135

$300

$141

$315

$295

$285

$283

$287

$1,120

% ACA Mandatory

0%

0%

0%

92%

100%

100%

100%

28%f

Source: Table prepared by CRS based on information from Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY2013 through FY2016, Rockville, MD. Numbers may not add up evenly due to rounding. Data are subject to updates to reflect changes in legislation.

a. Congress may choose to either maintain the current funding amount or authorize a different amount in its FY2016 final budget.

b. The Affordable Care Act (ACA) (P.L. 111-148) appropriated $300 million in mandatory funding for the NHSC to be used in FY2013. However, this amount was subject to the 5.1% non-exempt mandatory program spending reduction, resulting in $284.7 million. The sequestration order was issued pursuant to the Budget Control Act of 2011 (BCA) (P.L. 112-25), as amended, which established new budget enforcement mechanisms for reducing the federal deficit through FY2024.

c. The ACA appropriated $305 million in mandatory funding for the NHSC to be used in FY2014. However, this amount was subject to the 7.2% non-exempt mandatory program spending reduction, resulting in $283 million (see previous note).

d. The ACA appropriated $310 million in mandatory funding for the NHSC to be used in FY2015. However, this amount was subject to the 7.3% non-exempt mandatory program spending reduction, resulting in $287 million (see previous note).

e. The Medicare Access and CHIP Reauthorization Act (MACRA)(P.L. 114-10) amends the ACA (Section 10503(b)(2)(E)) to extend mandatory funding for the NHSC from FY2015 through FY2017, at the same level as FY2015, $310 million (the amount before the application of the 7.3% non-exempt mandatory program spending reductions).

f. This percentage reflects the portion that MACRA constitutes of the President's FY2016 budget request for NHSC.

In summary, funding provided by the ARRA in FY2009 and by the ACA in FY2011-FY2015 triggered short-term increases in NHSC resources for recruitment, and subsequent increases in field strength. While the CHCF might have been intended to supplement annual discretionary appropriations for the NHSC, it has become the sole source of funding for the NHSC program since FY2012. MACRA extends mandatory funding for the NHSC through FY2017.

Footnotes

 FY2016Enacted FY2017+/-FY2016 $285a $283b $287c $310d $310d            

Sources: Table prepared by CRS based on information from Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, Rockville, MD, volumes FY2013 through FY2017. Numbers may not add up evenly due to rounding. Data are subject to updates to reflect changes in legislation.

Notes: Abbreviations in the table and table notes are: ACA—Patient Protection and Affordable Care Act; BCA—Budget Control Act of 2011; CHCF—Community Health Center Fund; NHSC—National Health Service Corps; MACRA—Medicare Access and CHIP Reauthorization Act of 2015.

a. The ACA (P.L. 111-148, as amended) appropriated $300 million in mandatory funding for the NHSC to be used in FY2013. However, this amount was subject to the 5.1% non-exempt mandatory program spending reduction, resulting in $284.7 million. The sequestration order was issued pursuant to the BCA (P.L. 112-25), as amended, which established new budget enforcement mechanisms for reducing the federal deficit through FY2024. b. The ACA appropriated $305 million in mandatory funding for the NHSC to be used in FY2014. However, this amount was subject to the 7.2% non-exempt mandatory program spending reduction, resulting in $283 million (see previous note). c. The ACA appropriated $310 million in mandatory funding for the NHSC to be used in FY2015. However, this amount was subject to the 7.3% non-exempt mandatory program spending reduction, resulting in $287 million (see previous note). d. The MACRA (P.L. 114-10) amended the ACA (Section 10503(b)(2)(E)) to extend mandatory funding for the NHSC from FY2016 through FY2017, at $310 million. Unlike the prior three years, MACRA did not require a reduction in NHSC funding.

In FY2015, when authority for NHSC funding through the mandatory CHCF expired, Congress extended this funding through the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10).33 MACRA extended the mandatory CHCF, authorizing a transfer of funds to the NHSC, in the amount of $310 million for each of FY2016 and FY2017.

From FY2012 through FY2016,34 the CHCF has been the sole funding source for the NHSC, as Congress appropriated no discretionary funds to this program during this period.35 In each of FY2013 through FY2015, these mandatory funds have been subject to reductions due to sequestration required by the Budget Control Act of 2011 (BCA), as amended (see Table 2).36 On February 9, 2016, the Obama Administration released its FY2017 budget. The President's FY2017 budget request includes a total of $380 million for the NHSC, which would increase the NHSC budget by approximately 22% (+$70 million) over the previous year. The request consists of
  • $20 million in discretionary funds,
  • $50 million in new mandatory funds, and
  • $310 million in funds previously appropriated in MACRA.37

The President's FY2017 budget proposes that all new NHSC funding in FY2017 be directed to expand access to behavioral health services. Specifically, the request would expand the use of medication-assisted treatment (MAT) through investments in the NHSC, including loan repayment to clinicians with MAT training. The FY2017 budget also includes $25 million in new mandatory funding for FY2017 and FY2018 as part of an initiative by the Obama Administration to expand access to mental health care.38

The President's FY2017 request proposes funding that would support an increase in field strength by 27% over the previous year, thereby proposing to serve 10.7 million individuals (which would be an increase of 1.1 million individuals over the previous year).

Field Strength

NHSC field strength is the number of NHSC clinicians who are fulfilling a service obligation in a HPSA in exchange for a scholarship or loan repayment agreement.39 As of September 2015, total NHSC field strength was 9,683, which enabled NHSC clinicians to serve an estimated 10.2 million individuals in HPSAs.40

Changes in the size of the NHSC's field strength are, not surprisingly, shaped by appropriation levels.41 For example, increases in funding from FY2010 to FY2011 resulted in a 36% increase in field strength, from 7,530 to 10,279.

As the NHSC's field strength size has increased or decreased, the number of individuals served by NHSC clinicians has been correspondingly impacted. For example, in FY2011, when the NHSC appropriation peaked at $315 million, NHSC clinicians served 10.5 million individuals, compared to 9.3 million individuals in FY2013 and 10.2 million individuals in FY2015, respectively.42 The President's FY2017 budget, if enacted, would increase field strength size by as much as 11% above the FY2015 level, resulting in a projected field strength of 10,156 (see Figure 1).

Figure 1. Trends in NHSC Field Strength Size by Budget Source,FY2011-FY2017 (Est.) Composition As of FY2015 behavioral/mental health clinicians comprise the majority of the NHSC's field strength, and have done so since FY2010. Physicians and nurse practitioners are the next largest number of disciplines comprising NHSC field strength.43 Over time, Congress has requested that the Secretary consider adding other disciplines to the NHSC. In FY2015, Congress recognized the Secretary's authority to add other disciplines to the NHSC, and urged the Secretary to include pharmacists in the NHSC loan repayment and scholarship programs. In FY2012, the Secretary expanded eligibility for the NHSC State Loan Repayment Program (SLRP) to pharmacists (see Figure 2).44

The President's FY2017 budget request contains a first-time proposal that would target an increase in the number of behavioral/mental health providers in the NHSC. If authorized, this measure would add 351 behavioral health providers, and 878 mental health and opioid providers to the NHSC's field strength.45

Figure 2. NHSC Field Strength by Discipline as of September 2015

Author Contact Information

[author name scrubbed], Analyst in Health Resources and Services ([email address scrubbed], [phone number scrubbed])

Footnotes

Certain exceptions may affect this period-of-service requirement. For example, the period of service may be longer if an individual agrees to serve for more than two years, such as on a part-time basis, or if the scholarship or loan repayment benefit continues beyond the two-year minimum, at http://nhsc.hrsa.gov/.

The ACA was signed into law on Mar. 3, 2010 (P.L. 111-148, 124 Stat. 119). On Mar. 30, 2010, the President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which amended numerous health care and revenue provisions in the ACA and added multiple new stand-alone provisions. Congress and the President have since enacted several other bills that have made more targeted changes to specific ACA provisions.

. For more information, see HHS, NHSC, Scholarship Program Overview, http://www.nhsc.hrsa.gov/scholarships/overview/. These percentages exclude state loan repayment awards. FY2017 Justification of Estimations for Appropriations Committees, p.82-83; and Table 1 contains details on the types of loan repayment awards and scholarships. The most recent discretionary funding for the NHSC was for FY2011, when the NHSC received $24.8 million (see, Table 2). 36. FY2011 Justification of Estimations for Appropriations Committees, p. 69. In addition to this FY2017 request for NHSC funding to increase the number of health workers to provide opioid-related health services, the FY2017 budget includes $10 million for the Rural Opioid Overdose Reversal Program, which focuses on prevention, treatment, and intervention of opioid use in rural communities. See, FY2017 Justification of Estimations for Appropriations Committees, p. 13, FY2016, Rockville, MD, pp. 72 and 78.

1.

A health professional shortage area is an urban or rural location, a population group, or a medical facility where there is a critical need for health clinicians, at http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/designationcriteria.html.
2.

Certain exceptions may affect this period-of-service requirement. For example, the period of service may be longer if an individual agrees to serve for more than two years, such as on a part-time basis, or if the scholarship or loan repayment benefit continues beyond the two-year minimum, at http://nhsc.hrsa.gov/.

3.

P.L. 91-623 was enacted on Dec. 31, 1970. The NHSC is authorized in Sections 331-338 of the Public Health Service Act (42 U.S.C. §254d et. seq.).
4Trends in Funding As recent as FY2009 annual discretionary appropriations were the sole funding source for the NHSC since its inception in 1972.31 Now, the opposite is true with mandatory funding accounting for all (through FY2016) funding for NHSC. The ACA created a provision directing the CHCF to transfer $11 billion in mandatory funds over a five-year period (FY2011-FY2015) to support the NHSC and federal health center programs; the NHSC received various amounts beginning in FY2011, as shown in Table 2.32 Table 2. NHSC Funding, FY2011-FY2016, and the President's FY2017 Budget Request

(Dollars in millions)

Funding

FY2011

FY2012

FY2013

FY2014

FY2015

FY2017 Pres. Req.

Discretionary

$25

__

__

__

__

__

$20

+20

CHCF Mandatory

$290

$295

0

New B/M/H Mandatory

$50

+50

Total

$315

$295

$285

$283

$287

$310

$380

+$70

% CHCF

Mandatory

92%

100%

100%

100%

100%

100%

82%

0

Source: Prepared by CRS, based on data in Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, Rockville, MD, volumes FY2013-FY2016.

Notes: Base Field Strength represents clinicians who are supported through discretionary funds. ARRA Field Strength represents clinicians who are supported through "ARRA funds," which were appropriated in the American Recovery and Reinvestment Act of 2009 (ARRA; P.L. 111-5). ACA Field Strength represents clinicians who received appropriations through the mandatory Community Health Center Fund (CHCF), which was authorized in the Affordable Care Act (ACA) (P.L. 111-148). MACRA Field Strength represents clinicians supported by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10), which extends ACA mandatory funding for the NHSC in FY2016 and FY2017. Cumulative Field Strength represents total field strength for the year.

Source: Prepared by CRS, based on data in Department of Health and Human Services, Health Resources and Services Administration, FY2017 Justification of Estimations for Appropriations Committees, Rockville, MD, p. 75.

Notes: Allopathic physicians hold a Doctor of Medicine (M.D.) degree; osteopathic physicians hold a Doctor of Osteopathic Medicine (D.O.) degree. "Other State Loan Repayment Clinicians" may include registered nurses and pharmacists.
1.

For a list of NHSC-approved facilities and sites, see HHS, HRSA, National Health Service Corps Site Reference Guide, http://www.nhsc.hrsa.gov/downloads/sitereference.pdf.

2.

HHS, HRSA, Shortage Designation: Health Professional Shortage Areas & Medically Underserved Areas/Populations, http://www.hrsa.gov/shortage/. According to federal criteria for designating a HPSA, a shortage area can be an urban or rural location, a population group, or a medical facility where there is a critical need for health clinicians. HPSAs may be designated as having a shortage of primary medical care, dental, or mental health providers. The NHSC uses only HPSA data to determine need for clinicians.
3.

Allopathic (MD) or Osteopathic (DO) Physicians must be Board certified in a primary care specialty from a specialty board approved by the American Board of Medical Specialties or the American Osteopathic Association or have completed a residency program in a primary care specialty, approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association; and have a current, permanent, and unrestricted medical license that meets state licensure requirements. HHS, HRSA, National Health Service Corps Scholarship Program, Application and Program Guidance, Mar. 2016, https://nhsc.hrsa.gov/downloads/spapplicationguide.pdf, p. 6.

4.

The NHSC gives scholarships and loan repayments to U.S. citizens only. National Health Service Corps Scholarship Program, Application and Program Guidance, p. 6.

5.
6.

There are two federal designations for underservice: the Health Professional Shortage Area and the Medically Underserved Area and Population (MUA/P), see Shortage Designation: Health Professional Shortage Areas & Medically Underserved Areas/Populations. "Medically Underserved Areas/Populations are areas or populations designated by HRSA as having too few primary care providers, high infant mortality, high poverty or a high elderly population. Health Professional Shortage Areas (HPSAs) are designated by HRSA as having shortages of primary medical care, dental or mental health providers and may be geographic (a county or service area), population (e.g., low income or Medicaid eligible) or facilities (e.g., federally qualified health center or other state or federal prisons)," see HHS, HRSA Data Warehouse, http://datawarehouse.hrsa.gov/tools/analyzers/muafind.aspx. NHSC clinicians (loan repayers and scholars) must serve at an NHSC-approved service site; time spent at an unapproved site does not counts towards the clinician's service commitment, see HHS, HRSA, National Health Service Corps Loan Repayment Program, https://nhsc.hrsa.gov/loanrepayment/lrpapplicationguidance.pdf, p. 30; National Health Service Corps Scholarship Program, Application and Program Guidance, p. 24-25. Regarding NHSC site/location, a state's Primary Care Office (PCO) may coordinate the HPSA or MUA/P designation process, which could affect where an NHSC clinician is placed, National Health Service Corps Site Reference Guide, http://www.nhsc.hrsa.gov/downloads/sitereference.pdf, p. 22.

7.

CRS Report R43937, Federal Health Centers: An Overview, by [author name scrubbed].
8.

Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), FY2017 Justification of Estimations for Appropriations Committees, p. 79. (Hereinafter, Justification of Estimations for Appropriations Committees.)
9.

P.L. 91-623 was enacted on Dec. 31, 1970. The NHSC is authorized in Sections 331-338 of the Public Health Service Act (42 U.S.C. §254d et. seq.). The federal regulation states the purpose of the loan repayment (42 CFR § 62.21) and the scholarship program (42 CFR § 62.1).

10.

P.L. 111-148 was signed into law on Mar. 23, 2010, and subsequently amended.
511.

The CHCF is established in Section 10503 of the ACA—a Senate amendment defined its purpose. S.Amdt. 3276 (111th Congress), which amended H.R. 3590, the Patient Protection and Affordable Care Act, states that. The purpose of the CHCF iswas "to provide for expanded and sustained national investment in community health centers under section 330 of the Public Health Service Act and the National Health Service Corps."," according to S.Amdt. 3276 was agreed to on December 22, 2009. See CRS Report R43911, The Community Health Center Fund: In Brief, by [author name scrubbed](111th Congress), which amended H.R. 3590, ACA. The ACA provision for the CHCF expired in FY2015. For a discussion on the expiring mandatory CHCF, see CRS Report IN10185, Congress Faces Calls to Address Expiring ACA Funds for Primary CareR43911, The Community Health Center Fund: In Brief, by [author name scrubbed] and [author name scrubbed].
612.

Mandatory, or direct, spending generally refers to outlays from budget authority (i.e., the authority to incur financial obligations that result in government expenditures such as paying salaries, purchasing services, or awarding grants) that is provided in authorizing laws, as opposed to annual appropriations acts. Mandatory spending includes spending on entitlement programs (such as the Medicare and Social Security programs). See CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by [author name scrubbed].
713.

Federal health centers provide care to medically underserved populations regardless of their ability to pay. See CRS Report R42433, Federal Health Centers, by [author name scrubbed].

8.

The National Advisory Committee on Rural Health reported to the Secretary of HHS on these and other health care safety net programs in A Targeted Look at the Rural Health Care Safety Net, April 2002, http://www.hrsa.gov/advisorycommittees/rural/healthsafetynet.pdf.

9.

Rural Health Clinics (RHCs) are outpatient facilities located in rural areas. They aim to address an inadequate supply of physicians serving Medicare patients in rural areas and to increase the use of non-physician practitioners such as nurse practitioners and physician assistants in rural areas. See HHS, Centers for Medicare and Medicaid Services (CMS), Rural Health Clinics (Fact Sheet), http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf. Additional NHSC-eligible sites are FQHC Look-Alikes; School-Based Clinics (SBCs); Critical Access Hospitals (CAH); Community Mental Health Centers (CMHC); American Indian Health Facilities; correctional or detention facilities; state or local health departments; community outpatient facilities; and private practices. See HHS, HRSA, Justification of Estimations for Appropriations Committees, FY2016, Rockville, MD, pp. 72-73.
10.

For more information on the HHS budget, see CRS Report R43236, Labor, Health and Human Services, and Education: FY2014 Appropriations, coordinated by [author name scrubbed].
11.

Association of Clinicians for the Underserved, Save the NHSC, see hyperlink for "NHSC Stakeholder Letter to Congress," April 7, 2014, http://clinicians.org/save-the-national-health-service-corps/. NHSC Stakeholders consist of more than 50 health-affiliated professional groups and institutions that have a health care-related interest in underserved populations.

12.

HHS, HRSA, Justification of Estimations for Appropriations Committees, FY2016, Rockville, MD, p. 72.
13.

For more information, see http://www.nhsc.hrsa.gov/scholarships/overview/.

14.

For more information, see http://www.nhsc.hrsa.gov/loanrepayment.
15.

For more information, see http://nhsc.hrsa.gov/loanrepayment/studentstoserviceprogram/index.html. Health Professional Shortage Areas of the greatest need are designated by HRSA.
16.

For more information, see http://nhsc.hrsa.gov/loanrepayment/stateloanrepaymentprogram/index.html. Email communication from HHS, Office of Legislation, April 6, 2015.
17.

PHSA Section 338I(a)(2) requires that health professionals provide primary health care services. Within 42 C.F.R. §62.54, the State Loan Repayment Program 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.
18.

Email communication from HHS, Office of Legislation, December 12, 2013.
19.

HHS, HRSA, Justification of Estimations for Appropriations Committees, FY2016, Rockville, MD, p. 83.
20.

Division G—Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2015, Explanatory Statement of the Consolidated and Further Continuing Appropriations Act, 2015, Congressional Record, Daily Edition, vol. 160, no. 151—Book 2, part 1 (December 11, 2014), p. H9828.

21.

The CHCF received a mandatory appropriation of $11 billion, to be transferred to the NHSC and the federal health centers program over a five-year period from FY2011 through FY2015. The NHSC and the federal health centers program are administered by HRSA. For more discussion on the NHSC's budget through the ACA, see CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by [author name scrubbed].
22.

The ACA mandatory appropriation supported increases in field strength, but overall NHSC field strength declined from FY2011 through FY2013 (see Figure 2).

23.

These funds were directly appropriated to the CHCF. The ACA specified an annual amount to be transferred from the CHCF to the NHSC each year.
24According to HRSA, "Federally qualified health centers (FQHCs) include all organizations receiving grants under Section 330 of the Public Health Service Act (PHS). FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits. FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors. Certain tribal organizations and FQHC Look-Alikes (an organization that meets PHS Section 330 eligibility requirements, but does not receive grant funding) also may receive special Medicare and Medicaid reimbursement," HHS, HRSA, What are Federally qualified health centers?," http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/qualified.html. See CRS Report R43937, Federal Health Centers: An Overview, by [author name scrubbed].
14.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10) was signed by the President on Apr. 16, 2015. MACRA amended Section 10503(b)(2)(E) of the ACA, and extended the CHCF through FY2017. For information on MACRA, see CRS Report R43962, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10), coordinated by [author name scrubbed].
15.

Section 5602 of the ACA mandated the Secretary of HHS to create a "Negotiated Rulemaking Committee on Designation of MUPs and HPSAs" to review criteria for the designation of Medically Underserved Areas and Health Professional Shortage Areas and MUA/Ps. The committee released a report on Oct. 1, 2011, but the Committee's report was not unanimous; therefore, the Secretary is not required to use the report when drafting the new rule. For the Committee's report, see http://www.hrsa.gov/advisorycommittees/shortage/nrmcfinalreport.pdf. As of the publication date of this CRS report, HRSA has not released a final rule.
16.

Teaching health centers support residency training in primary care and dentistry in community-based, ambulatory settings. FY2015 Justification of Estimations for Appropriations Committees, http://www.hrsa.gov/about/budget/budgetjustification2015.pdf.
17.

The law requires that a state's matching funds for NHSC State Loan Repayment Program consist of non-federal contributions in cash in an amount equal to a minimum of $1 for each $1 of federal funds provided in the grant (42 U.S.C. § 254q–1 (b).
18.

See, federal regulations at 42 CFR § 62.51 through §62.58 (Subpart C—Grants for State Loan Repayment Programs).
19.
20.

Respectively, 42 U.S.C. § 254l-1, as amended; and 42 U.S.C. § 254d(i), as amended.
21.

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 (i.e., a Psychiatrist), Nurse Practitioner (i.e., a Psychiatric Nurse Specialist), or Physician Assistant (i.e., Mental Health & Psychiatry). See HHS, HRSA, National Health Service Corps Loan Repayment Program, FY2016, Jan. 2016, p. 7, https://nhsc.hrsa.gov/loanrepayment/lrpapplicationguidance.pdf.
22.

Severity of need is determined by a scoring process that the Secretary applies to each designated area. A high-need HPSA is defined as a HPSA score of 14 or above; the higher the score, the greater the need for an NHSC clinician, National Health Service Corps Loan Repayment Program, FY2016, Jan. 2016, p. 4-5.

23.

42 U.S.C. § 254l1(a)(2) requires the Secretary to establish an NHSC loan repayment program to recruit health professionals as needed.
24.

Students must complete a residency in family practice, general internal medicine, general pediatrics, general psychiatry, obstetrics-gynecology, internal medicine/family practice, or internal medicine/pediatrics.
25.

In FY2016, for the S2S Program, sites with HPSAs scores of 14 or above are determined to be of high-need. See HHS, HRSA, National Health Service Corps, Students to Service Loan Repayment Program, FY2016, http://nhsc.hrsa.gov/loanrepayment/studentstoserviceprogram/applicationguidance.pdf, p. 5.

26.

Students to Service Loan Repayment Program, FY2016, pp. 6-7.
27.

PHSA Section 338I(a)(2) (42 U.S.C. § 254q–1) authorizes the Secretary to make grants to states for the NHSC State Loan Repayment program provided that a state agency agrees to administer the program. Within 42 CFR § 62.54, the state agencies administering the State Loan Repayment Program 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, see HHS, State Loan Repayment Contacts, http://nhsc.hrsa.gov/loanrepayment/stateloanrepaymentprogram/contacts.html.

28.

Email communication from HHS, HRSA, Office of Legislation, Dec. 12, 2013.
29.
30.

In FY2011, the NHSC received $315 million in appropriated funds, representing a 121.8% increase over the previous year (from $141 million in FY2010 to $315 million in FY2011) (see, "Trends in Funding" in this report).

31.

For more information on the HHS budget, see CRS Report R44287, Labor, Health and Human Services, and Education: FY2016 Appropriations, coordinated by [author name scrubbed] and [author name scrubbed].
32.

These funds were directly appropriated to the CHCF. The ACA specified an annual amount to be transferred from the CHCF to the NHSC each year.
33.

See CRS Report R43962, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10), coordinated by [author name scrubbed].
34.
35.

The NHSC and the federal health centers program are administered by HRSA. For more discussion on the NHSC's budget through the ACA, see CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by [author name scrubbed].

The Budget Control Act of 2011 (BCA) amended the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA). "Sequestration" is a process of automatic spending reductions where budgetary resources are permanently canceled to achieve certain budget policy goals. The process was first authorized by the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA, Title II of P.L. 99-177, commonly known as the Gramm-Rudman-Hollings Act). See CRS Report R42050, Budget "Sequestration "and Selected Program Exemptions and Special Rules, coordinated by [author name scrubbed].

25.

The President signed P.L. 114-10 into law on April 16, 2015, amending Section 10503(b)(2)(E) of the ACA. See Table 2 for funding amounts.

26.

HHS, HRSA, Justification

37.

FY2017 Justification of Estimations for Appropriations Committees, p.17.
38.

FY2017 Justification of Estimations for Appropriations Committees, p. 11.
39.

National Advisory Council on the National Health Service Corps, Meeting Minutes Summary , HHS, Hilton Washington, DC/Rockville Hotel & Executive Meeting Center, Rockville, MD, Rockville, MD, 2012, p. 2, https://nhsc.hrsa.gov/corpsexperience/aboutus/nationaladvisorycouncil/meetingsummaries/011912minutes.pdf.
40.

Total NHSC field strength includes only those providers that are fulfilling a service obligation for a scholarship or loan repayment. Total NHSC field strength excludes providers, who are not obligated to the NHSC. Non-obligated providers and NHSC providers may serve alongside each other in the same HPSA..
41.

See section on "Funding" for a detailed discussion of these NHSC funding sources.
42.

Justification of Estimations for Appropriations Committees, for volumes FY2013, FY2015, and FY2017.

43.
44.

FY2017 Justification of Estimations for Appropriations Committees, pp. 426-427.
45.