Contents

• Introduction
• Brief History
Funding
• Recruitment and Retention Programs
• Federal Scholarship Program
• Federal Loan Repayment Program
• Federal Students to Service (S2S) Loan Repayment Program
• State Loan Repayment Program
• Special Loans for Former Corps Members to Enter Private Practice
• Trends in Recruitment
• Trends in Funding
• Field Strength
• Field Strength and Composition

Summary

The National Health Service Corps (NHSC) is a pipeline for clinician recruitment and training. Its program objective is to increase the availability of primary care services to populations in Health Professional Shortage Areas (HPSAs). It aims to increase clinician availability by making loan repayment and scholarship awardsrepayments and awarding scholarships to individuals in exchange for their agreement to serve as NHSC clinicians (or providers) at approved sites. NHSC cliniciansproviders are mainly physicians, physician assistants, nurse practitioners, and behavioral/mental health professionals who must serve for a minimum of two years at an approved facility. An approved facility, for example, may be a Federally Qualified Health Center (FQHC) and FQHC Look-Alike, American Indian and Native Alaska Health Clinic, Rural Health Clinic, Critical Access Hospital, School-Based Clinic, Mobile Unit, Free Clinic, or Community Mental Health Center, and must be located in a federally designated health professional shortage areaHPSA. All NHSC cliniciansproviders must fulfill a minimum of two years of NHSC service-year service commitment at an NHSC-approved site. The NHSC is administered by the Health Resources and Services Administration (HRSA), within the Department of Health and Human Services (HHS).

Congress establishedcreated the NHSC in the Emergency Health Personnel Act of 1970 (P.L. 91-623), and since then has reauthorized and amended its programs several times. The Patient Protection and Affordable Care Act of 2010 (ACA; P.L. 111-148) permanently reauthorized the NHSC. Legislation to potentially repeal or replace all or parts of the ACA, depending on its scope, may impact NHSC authorization and funding. In 2010, Congress implemented major revisions in the NHSC through the ACA and has amended and reauthorized the program several times since its inception. In 2010, Congress implemented major revisions in the NHSC in the Patient Protection and Affordable Care Act of 2010 (ACA; P.L. 111-148). Most notably, the ACA permanently authorized the NHSC and created the Community Health CentersCenter Fund (CHCF), a source of mandatory funding for the NHSC from FY2011 through FY2015. AdditionallyThis funding was subsequently extended in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10). MACRA provided $310 million to support the NHSC in FY2016 and FY2017 through the CHCF. MACRA is the sole source of NHSC funds in FY2017. (Because this fund is subject to the mandatory spending sequester, the FY2017 funding level is $289 million.) In addition, the ACA amended statutory authorities pertaining to the NHSC's requirements for 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 federally designated HPSAs.

In FY2015, the most recent annual data available, the NHSC awarded 2,934 new loan repayment agreements; 1,841 continuing loan repayment agreements; 96 student-to-service loan repayments; 620 state loan repayments; 196 new scholarships; and 11 continuing scholarships.

In FY2016, an estimated 9,100 NHSC clinicians are providing medical, dental, and other health care services to approximately 9.2 million individuals in rural and urban HPSAs. In addition, in FY2016, the NHSC is planning to award an estimated 2,654 new loan repayment agreements; 1,732 continuing loan repayment agreements; 117 student-to-service loan repayments; 433 state loan repayments; 165 new scholarships; and 16 continuing scholarships. During the five-year period from FY2011 through FY2016, the number of new NHSC awards averaged 5,595. In FY2014, the NHSC issued the largest number of awards, 5,620, in a single year. In FY2016, mentalMental health providers, physicians, and nurse practitioners representrepresented the largest number of NHSC clinicians. In in recent years. Also, in recent years, congressional appropriators have expressed concerns about updating the methodology for designating areas where NHSC providers are placed, and interest in the possibility of authorizing pharmacists as NHSC clinicians.

For FY2016, the CHCF funded 100% of the NHSC budget. Funding for the CHCF was extended in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10). MACRA provided $310 million to support the NHSC in each of FY2015 through FY2017. The President's FY2017 budget request contains a request of $380 million, which includes $20 million in discretionary funds for behavioral/mental health initiatives, and $50 million in new mandatory funding for two treatment initiatives associated with opioid disorders (in addition to the extant $310 million in mandatory funding appropriated through MACRA).

The 21^st Century Cures Act (P.L. 114-255) expanded the list of NHSC providers to include child and adolescent psychiatrists. This report summarizes the NHSC's recruitment and retention programs, and the NHSC's funding historytrends from FY2010 through FY2016, and the FY2017 President's budget requestFY2017.

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National Health Service Corps: Background and Trends in, Funding, and Programs and Recruitment

Introduction

The National Health Service Corps (NHSC) is a clinician recruitment and retention program that Congress created to reduce health workforce shortages in locations where cliniciansproviders historically have not served or have not served in numbers sufficient to address the needs of the local population. The NHSC consists of federal and state programs that recruit qualified individuals who agree to serve at approved facilities¹ located in federally designated health professional shortage areas (HPSAs)² 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 ato, and makes loan repayment agreements with, individuals; the state programs make loan repayment agreements, only, to individuals. All NHSC scholars and loan repayers (federal and state) must agree to serve for a minimum of two years³ at an NHSC-approved facility that is located in a HPSA.⁴ The federal portion of the NHSC program awards scholarships to individuals studying in (1) a qualified academic program that leads to a degree in medicine (allopathic or osteopathic)⁵ or a degree in dentistry, or (2) a qualified program that trains physician assistants, nurse-midwives, or nurse practitioners. Further, 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). Because 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 with eligible providers who may be dental hygienists and mental and behavioral/mental health (BMH) providers, in addition to the aforementioned list of professionals who are scholarship-eligible.⁶ In December 2016 Congress passed legislation to clarify that child and adolescent psychiatrists are eligible providers for the NHSC loan repayment program.⁷

  The state portion of the NHSC's loan repayment program may support all providers who are eligible to participate in the federal scholarship and loan repayment programs, and each state may choose to expand the list of eligible providers to include those who are trained in other disciplines (such as pharmacy or optometry).

  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 was created in the Emergency Health Personnel Act of 1970⁸ to provide an adequate supply of trained health providers in federally designated HPSAs. Throughout its four decades of existence, legislators have authorized and revised the program several times, with the most recent authorization in the Patient Protection and Affordable Care Act (ACA).⁹ In 2010, Congress permanently authorized the NHSC in the ACA. In addition, the ACA

• established the Community Health Center Fund (CHCF),¹⁰ which authorized mandatory appropriations¹¹ for the NHSC (and the Federal Health Centers Program)¹² from FY2011 through FY2017;¹³
• required the Secretary of HHS to redefine how HPSAs and Medically Underserved Areas/Populations are designated;¹⁴
implemented a part-time option from which NHSC clinicians (or providers) 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 centers¹⁶15 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 (PHSAIn addition to this background, this report provides funding trends from FY2011 through FY2017, and a summary of the programs for the NHSC. Funding Until FY2009, and dating back to its inception in 1972, annual discretionary appropriations were the sole funding source for the NHSC.¹⁶ Now the opposite is true, with mandatory funding accounting for all (through FY2017) funding for NHSC. The ACA created the CHCF and provided mandatory funding for it over a five-year period (FY2011-FY2015). The act also directed the transfer of $11 billion total from the CHCF over that period to support the NHSC and federal health center programs; the NHSC received various amounts beginning in FY2011. For FY2016 and FY2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10)¹⁷ extended the CHCF funding for the NHSC funding transfers, as shown in Table 1.¹⁸ The FY2017 NHSC funding level is $288.6 million for this program, following a mandatory spending sequester for FY2017 of 6.9% (pursuant to the Balanced Budget and Emergency Deficit Control Act of 1985, as amended).¹⁹ Table 1. National Health Service Corps (NHSC) Funding, FY2011-FY2017

(Dollars in millions)

Funding

FY2011

FY2012

FY2013

FY2014

FY2015

FY2016

FY2017

Discretionary

$25^a

__

__

__

__

__

__

Mandatory

$290

$295

$300^b $305^c $310^d $310^e $310^f

Final

$315

$295

$285

$283

$287

$310

$289

% Mandatory

92%

100%

100%

100%

100%

100%

100%

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. The FY2017 amount is provided by the Department of Human Services (HHS), Health Resources and Services Administration (HRSA), Office of Legislation (OLA). Data are subject to updates to reflect changes in legislation.

Notes: Abbreviations in the table and table notes are: ARRA—American Recovery and Reinvestment Act of 2009; ACA—Patient Protection and Affordable Care Act; BBEDCA—Balanced Budget and Emergency Deficit Control Act of 1985; CHCF—Community Health Center Fund; NHSC—National Health Service Corps; MACRA—Medicare Access and CHIP Reauthorization Act of 2015; and Office of Management and Budget (OMB).

a. ARRA represented a source of discretionary funds that were appropriated to the NHSC in FY2009, but those funds are not considered to be a FY2011 appropriation. Still, they were reflected in the FY2011 budget. ARRA contributed $57 million (not shown in the table) for federal loan repayments. See Justification of Estimations for Appropriations Committees, Rockville, MD, vol. FY2013, p. 76. b. 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% mandatory spending sequestration, resulting in a total of $284.7 million for FY2013. The sequestration order was issued pursuant to the BBEDCA, as amended. See footnote 32 for further information. c. ACA appropriated $305 million in mandatory funding for the NHSC to be used in FY2014. However, this amount was subject to the 7.2% mandatory spending sequestration, resulting in $283 million (see footnote 32). d. ACA appropriated $310 million in mandatory funding for the NHSC to be used in FY2015. However, this amount was subject to the 7.3% mandatory spending sequestration, resulting in $287 million (see footnote 32). e. MACRA (P.L. 114-10) extended mandatory funding for the NHSC, as part of the CHCF, for FY2016 and FY2017, at $310 million in mandatory funding each fiscal year. However, this funding extension was enacted after 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. (See OMB Report to Congress on the Joint Committee Reductions for Fiscal Year 2016, February 2, 2015, available at https://obamawhitehouse.archives.gov/sites/default/files/omb/assets/legislative_reports/sequestration/2016_jc_sequestration_report_speaker.pdf.) f. MACRA appropriated $310 million in mandatory funding for the NHSC to be used in FY2017. (See table note "e" for an explanation on the MACRA appropriation.) However, this amount is subject to the 6.9% mandatory spending sequestration, resulting in $289 million (see footnote 32). From FY2012 through FY2016,²⁰ the CHCF was the sole funding source for the NHSC, as no discretionary funds were appropriated to this program during this period.²¹ In each of FY2013 through FY2015, these mandatory funds were subject to the mandatory spending sequestration that was required by the Balanced Budget and Emergency Deficit Control Act of 1985, as amended.²²

In FY2015, when authority for NHSC funding through the CHCF expired, this authority was extended through the enactment of MACRA on April 16, 2015. MACRA extended the mandatory funding for the CHCF and authorized a transfer of funds to the NHSC in the amount of $310 million for each of FY2016 and FY2017. However, because this funding extension was enacted after the mandatory spending sequester for FY2016 was calculated by OMB, the FY2016 funding for the NHSC was not included in OMB's sequester calculation, and thus no sequester was ordered. The final FY2016 funding for the NHSC was $310 million, whereas the final FY2017 funding level is estimated to be $288.6 million due to the 6.9% mandatory sequester for FY2017.²³

Recruitment and Retention Programs Various sections in Title III of the Public Health Service Act (PHS Act) 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.¹⁷24 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.¹⁸25

Federal Scholarship Program

PHSA Section 338A establishes the NHSC Scholarship Program, which recruits students who are enrolled in medical school, physician assistant schoolprograms, dental school, or advance practice nursing school. Qualified individualsstudents may receive financial support through scholarships, which include tuition, reasonable education expenses, and a monthly living stipend. StudentsThey 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 a HPSA. For example, if a qualified student getsfull-time service a scholar receives three years of scholarship support theythe scholar would owe sixthree years of full-time service.¹⁹

at an approved facility.²⁶ The number of school years of NHSC scholarship support received by the scholar may not exceed four school years.²⁷

Federal Loan Repayment Program

PHSA Sections 338B and 331(i)²⁰28 establish the Federal Loan Repayment Program, which is designed to recruit licensed professionals, including physicians, physician assistants, dentists, dental hygienists, advanced practice nurses, and behavioral/mental health workers.²¹29 These professionals must be employed or have accepted an offer to be employed at an NHSC-approved work site. Federal loan repayers have a choice of service options based on full- or part-time service.

For full-time service, an individuala loan repayer 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.²²30 Also, for full-time service, an individuala loan repayer 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.

Federal Students to Service (S2S) Loan Repayment Program

PHSA Section 338B²³31 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 residency²⁴32 in a HPSA of the greatest need for at least three years (full time-time option) or six years (half time).²⁵ Alternatively-time option).³³ Instead of completing a primary care residency, 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

34

State Loan Repayment Program

PHSA Section 338I³⁵ 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 canmay choose to expand or contract the number of clinicians (or providers) 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 338G³⁶ 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

37

Trends in Recruitment

Within the past five years, from FY2011 through FY2015From FY2011 through FY2016, the most recent data, the NHSC offered more thanan estimated 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 The NHSC awarded an estimated 15,303 new federal loan repayments from FY2011 through FY2016, averaging 3,061 new federal loan repayments annually. A significant increase in new federal loan repayments was awarded in FY2011, when the NHSC awarded 4,113 new federal loan repayments, the largest number of new loan repayments issued in a single year due toduring FY2011-FY2015. This increase was made possible by a larger program appropriation in FY2011.³⁸.³⁰ Table 12 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.

(the FY2017 operating budget is not yet available).

Trends 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

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.)

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.

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

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.

Author Contact Information

Footnotes

The ACA was signed into law on March 3, 2010 (P.L. 111-148, 124 Stat. 119). On March 30, 2010, President Obama 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. Since the law was passed, Congress and the President have since President Obama have enacted several other bills that have made more targeted changes to specific ACA provisions.

The most recent discretionary funding for the NHSC was for FY2011, when the NHSC received $24.8 million (see Table 1). 30. National Advisory Council on the National Health Service Corps, Meeting Minutes Summary" in this report).

The 21^st Century Cures Act (P.L. 114-255), enacted on December 13, 2016 specified such eligibility in Title IX, Subtitle B, Section 9023, Clarification On Current Eligibility For Loan Repayment Programs. The act requires the Administrator of HRSA to clarify provider eligibility regarding PHSA Section 338B(b)(1)(B), which is the NHSC Loan Repayment Program. Note that although psychiatrists are physicians, they are counted as mental health professionals within the NHSC; they are counted separately from primary care physicians.

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 (or providers). 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.	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/.
64.	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 cliniciansproviders (loan repayers and scholars) must serve at an NHSC-approved service site; time spent at an unapproved site does not countscount 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, ppp. 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.
75.	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.	The ACA was signed into law on Mar. 3, 2010 (P.L. 111-148, 124 Stat. 119). On Mar. 30, 2010, the PresidentAllopathic (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, March 2016, https://nhsc.hrsa.gov/downloads/spapplicationguide.pdf, p. 6.
6.	The NHSC gives scholarships and loan repayments to U.S. citizens only. National Health Service Corps Scholarship Program, Application and Program Guidance, p. 6.
7.	The 21st Century Cures Act (P.L. 114-255), enacted on December 13, 2016 specified such eligibility in Title IX, Subtitle B, Section 9023, Clarification On Current Eligibility For Loan Repayment Programs. The act requires the Administrator of HRSA to clarify eligibility for individuals who are considering the NHSC Loan Repayment Program, which is established in the PHSA Section 338B(b)(1)(B).
8.	P.L. 91-623 was enacted on December 31, 1970. The NHSC is authorized in Sections 331-338 of the PHS Act (42 U.S.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).
9.
1110.	The CHCF is established in Section 10503 of the ACA. The purpose of the CHCF was "to provide for expanded and sustained national investment in community health centers under sectionSection 330 of the Public Health ServicePHS Act and the National Health Service Corps," according to S.Amdt. 3276 (111th Congress), which amended H.R. 3590, ACA. The ACA provision for the CHCF expired in FY2015. For a discussion on the CHCF, see CRS Report R43911, The Community Health Center Fund: In Brief, by [author name scrubbed].
1211.	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].
1312.	According to HRSA, "Federally qualified health centers (FQHCs) include all organizations receiving grants under Section 330 of the Public Health Service Act (PHS)PHS Act. 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 meetsorganizations that meet PHS Section 330 eligibility requirements, but doesdo not receive grant funding) also may receive special Medicare and Medicaid reimbursement," HHS, HRSA, What are FederallyFederally 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]. (see Appendix B).
1413.	The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10) was signed by the President on Apr.President Obama on April 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].
1514.	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/Psfederally designated areas where health care resources or professionals may not be adequate. The committee released a report on Oct.October 1, 2011, but the Committee's report wasits recommendations were not unanimous; therefore, the Secretary is not required to use the reportimplement the recommendations when drafting thea new rule. For the Committeecommittee'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.
1615.	Teaching health centers support residency training in primary care and dentistry in community-based, ambulatory settings. FY2015FY2017 Justification of Estimations for Estimations for Appropriations Committees, http://www.hrsa.gov/about/budget/budgetjustification2015budgetjustification2017.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.	For more information, see HHS, NHSC, Scholarship Program Overview, http://www.nhsc.hrsa.gov/scholarships/overview/.
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.
2216.	For more information on the HHS budget, see CRS Report R44691, Labor, Health and Human Services, and Education: FY2017 Appropriations.
17.	See CRS Report R43962, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10), coordinated by [author name scrubbed].
18.	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.
19.	The Balanced Budget and Emergency Deficit Control Act of 1985 was amended by the Budget Control Act of 2011 (BCA, P.L. 112-25) to provide a budget process mechanism that would reduce mandatory spending and further reduce discretionary spending over an extended period. For mandatory spending, the reductions are to occur through "sequestration" in each of fiscal years between FY2013-FY2025. (As originally enacted in the BCA, mandatory sequestration was scheduled to run through FY2021, but this period has subsequently been incrementally extended to FY2025 by P.L. 113-67, P.L. 113-82, and P.L. 114-74.)
20.
21.	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.	P.L. 99-177. See footnote 32 for further information about the Balanced Budget and Emergency Deficit Control Act of 1985 and sequestration.
23.	OMB calculated that the percentage reduction rate for nonexempt nondefense mandatory spending in FY2017 is 6.9%. All the CHCF funding for the NHSC is subject to this 6.9% reduction. See OMB Report to Congress on the Joint Committee Reductions for Fiscal Year 2017, February 9, 2016, available at https://obamawhitehouse.archives.gov/sites/default/files/omb/assets/legislative_reports/sequestration/jc_sequestration_report_2017_house.pdf. For more detail on the OMB calculation, see CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by [author name scrubbed] (see Appendix B).
24.	The law requires that a state's matching funds for NHSC State Loan Repayment Program consist of nonfederal 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).
25.	See, federal regulations at 42 C.F.R. §62.51 through §62.58 (Subpart C—Grants for State Loan Repayment Programs).
26.	Each year, the NHSC uses HPSA scores to determine where NHSC scholars will be placed. For example, from October 1, 2016, through September 30, 2017, NHSC scholars must work at NHSC-approved service sites with a HPSA score of 17 or above for their discipline. HHS, HRSA, NHSC Scholarship Program, School Year 2017-2018 Application & Program Guidance, https://nhsc.hrsa.gov/downloads/spapplicationguide.pdf.
27.	NHSC Scholarship Program, School Year 2017-2018 Application & Program Guidance, p. 10.
28.	42 U.S.C. §254l-1, as amended; and 42 U.S.C. §254d(i), as amended, respectively.
29.	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, including Child and Adolescent Psychiatrists), 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, FY2017, January 2017, pp. 10-17, https://nhsc.hrsa.gov/loanrepayment/lrpapplicationguidance.pdf.
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. FY2017, January 2017, pp. 16-17.
2331.	42 U.S.C. § 254l1(a)(2) requires the Secretary to establish an NHSC loan repayment program to recruit health professionals as needed.
2432.	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.
2533.	In FY2016FY2017, 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 CorpsNational Health Service Corps, Students to Service Loan Repayment Program, FY2016,, FY2017, http://nhsc.hrsa.gov/loanrepayment/studentstoserviceprogram/applicationguidance.pdf, p. 517.
2634.	StudentsNational Health Service Corps, Students to Service Loan Repayment Program, FY2016FY2017, pp. 6-7.
2735.	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 § C.F.R. §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.
2836.	Email communication from HHS, HRSA, Office of Legislation, Dec. 12, 201342 U.S.C. §254p.
2937.	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 scholarshipsEmail communication from HHS, HRSA, Office of Legislation, December 12, 2013.
3038.	In FY2011, the NHSC received a total of $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 "Funding" in this report).	39.
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.	The most recent discretionary funding for the NHSC was for FY2011, when the NHSC received $24.8 million (see, Table 2).
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].
36.	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).
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.This total excludes NHSC alumni that serve in HPSAs alongside NHSC providers but do not have a service obligation. Providers who serve in HPSAs but do not have an NHSC service obligation, such as those who are included in NHSC in retention efforts, are not counted in the NHSC's field strength.
41.	See section on "Funding" Funding"for a detailed discussion of these NHSC funding sources.
42.	Justification of Estimations for Appropriations Committees, for volumes FY2013, FY2015, and FY2017.
43.	FY2011 Justification of Estimations for Appropriations Committees, p. 69.
44.	FY2017 Justification of Estimations for Appropriations Committees, pp. 426-427.
45.	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. 13HRSA FY2017 Justification, p. 75. Advanced Practice Nurses (APNs) make up 21% of the NHSC's workforce; 2% of these are nurse-midwives. According to the Joint APRN Joint Dialogue Group Report (of the American Nurses Association), July 7, 2008: "APRNs include certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists and certified nurse practitioners," https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf.	46.