Contents

• Introduction
• Program Overview
• Federal Scholarship Program
• Federal Loan Repayment Program
• Main Loan Repayment Program
• Federal Students to Service (S2S) Loan Repayment Program
• Substance Use Disorder Repayment Program
• Rural Community Loan Repayment Program
• State Loan Repayment Program
• NHSC Funding
• Program Size
• Recruitment
• Field Strength
• Types of NHSC Providers
• NHSC Provider Locations
• Provider Retention
• Legislative Proposals Related to the NHSC

Summary

The National Health Service Corps (NHSC) provides scholarships and loan repayments to health care providers in exchange for a period of service in a health professional shortage area (HPSA). The program places clinicians at facilities—generally not-for-profit or government-operated—that might otherwise have difficulties recruiting and retaining providers. In FY2024, the program supported nearly 25,000 clinicians. The program's clinicians provided care to an estimated 19.3 million patients in 2023.

The NHSC is administered by the Bureau of Health Workforce (BHW) within the Health Resources and Services Administration (HRSA), within the Department of Health and Human Services (HHS). On March 27, 2025, HHS issued a press release and fact sheet announcing that HHS was being restructured. The fact sheet indicated that this restructuring would combine HRSA into a new entity. At the time of this report's publication, the potential effect of this restructuring on NHSC and its administration are unknown.

Congress created the NHSC in the Emergency Health Personnel Act of 1970 (P.L. 91-623), and its programs have been reauthorized and amended several times since then. The NHSC consists of three programs: (1) a federal scholarship program; (2) a federal loan repayment program, which includes several temporary component loan repayment programs (the substance use disorder loan repayment program, the rural community workforce loan repayment program, and the Student to Service loan repayment program); and (3) a state-operated loan repayment program.

The Patient Protection and Affordable Care Act of 2010 (ACA; P.L. 111-148) permanently reauthorized the NHSC. Prior to the ACA, the NHSC had been funded with discretionary appropriations. The ACA created a new mandatory funding source for the NHSC, the Community Health Center Fund (CHCF), which was intended to supplement the program's annual appropriation. However, from FY2012 to FY2017, the CHCF entirely replaced the NHSC's discretionary appropriations. Beginning in FY2018, the program received discretionary appropriations again. These funds were appropriated for loan repayment for substance use disorder treatment providers, with some funds reserved for loan repayment for providers placed at rural facilities and at Indian Health Service facilities. In FY2021, the American Rescue Plan Act of 2021 (ARPA, P.L. 117-2) provided a one-time appropriation of $800 million to expand the number of scholarship and loan repayment awards the program can make. ARPA also reserved $100 million for states to make loan repayment awards.

Though the NHSC has received discretionary appropriations in recent years, the CHCF represents more than 70% of the program's annual funding. The CHCF is time-limited. At its outset, it was an appropriation for FY2011 through FY2015, but it has been extended several times, most recently through March 15, 2025, in the FY2025 Further Continuing Appropriations Act (P.L. 118-158).

From FY2011 through FY2023, the NHSC offered more than 91,579 loan repayment agreements and scholarship awards to individuals who have agreed to serve for a minimum of two years in a HPSAs. In FY2023, the NHSC offered more than 8,000 loan repayment agreements and scholarship awards. The number of awards the NHSC makes is only one component of program size, because not all awardees are currently serving as NHSC providers; some are still completing their training (e.g., scholarship award recipients). As such, the NHSC also measures its field strength: the number of NHSC providers who are fulfilling a service obligation in a HPSA in a given year. In FY2023, total NHSC field strength was 18,335. NHSC providers are currently serving in a variety of settings throughout the entire United States and its territories. The majority of NHSC providers serve in outpatient settings, most commonly at federally qualified health centers.

Introduction

The National Health Service Corps (NHSC) is a clinician recruitment and retention program that aims to reduce health workforce shortages in underserved areas. The NHSC has three components: (1) a federal scholarships program, (2) a federal loan repayment program, and (3) a state-operated loan repayment program. Under each of these programs, health providers receive either scholarships or loan repayments in exchange for a service commitment at an NHSC-approved facility located in a federally designated health professional shortage area (HPSA, see text box).¹ Participants in the state loan repayment programs may also serve in state-designated shortage areas; federal program participants may not. NHSC-approved facilities are generally nonprofit or government-operated (federal, state, local, or tribal) organizations that provide care to patients without regard for the patient's ability to pay. The program's clinicians provided care to an estimated 19.3 million patients in 2023.

The three NHSC programs are managed by 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). On March 27, 2025, HHS issued a press release and fact sheet announcing that HHS was being restructured.² The fact sheet indicated that this restructuring would consolidate HRSA and other agencies into a new entity. At the time of this report's publication, the potential effect of this restructuring on NHSC and its administration are unknown.

The NHSC was created by the Emergency Health Personnel Act of 1970 to provide an adequate supply of trained health providers in federally designated HPSAs.³ Since the program's inception, Congress has reauthorized and revised the program several times, with the most recent reauthorization included in the Patient Protection and Affordable Care Act (P.L. 111-148, ACA). The ACA permanently reauthorized the NHSC, creating, among other things, a mandatory funding stream for the program and implementing a part-time option, which allows part-time service in exchange for an extended service commitment.⁴

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

Program Overview

The NHSC consists of three programs: (1) a federal scholarship program; (2) a federal loan repayment program, which includes several temporary component loan repayment programs (the substance use disorder loan repayment program, the rural community workforce loan repayment program, and the Student to Service loan repayment program); and (3) a state-operated loan repayment program. The federal scholarship program provides scholarships in exchange for a service commitment at the end of a recipient's education, including after any training required before licensure. The loan repayment programs provide clinicians with loan repayment in exchange for an immediate service commitment.⁵ HRSA administers the federal scholarship and loan repayment programs and provides funds to states. States match these funds to operate state loan repayment programs.⁶ The largest program—by funding and by participants—is the federal loan repayment program, followed by the state loan repayment program, and then the scholarship program.

The section below describes these three programs. The discussion focuses on program differences; however, the programs share a number of common elements. Specifically, the core programs generally require a minimum service commitment of two years in a HPSA.⁷ Several of the component loan repayment programs require a three-year service commitment, including the substance use disorder loan repayment program, the rural community workforce loan repayment program, and the Student to Service loan repayment program (these programs are discussed below). All NHSC programs are restricted to U.S. citizens or U.S. nationals,⁸ and all provide awards that are exempt from federal income and employment taxes. In addition, all three programs allow physicians,⁹ dentists, physician assistants, nurse midwives, and nurse practitioners to participate, but the loan repayment programs also permit additional provider types to participate.¹⁰ The three program types are described below; Table 2 presents data on the number of awards made under each of these programs.

Generally, NHSC awards are made competitively, with scholarships awarded based on eligibility and a set of selection factors (e.g., the participant's commitment to primary care practice and the likelihood of remaining in a shortage area after the NHSC service commitment has ended).¹¹ Loan repayment awards are made based on the HPSA score of the site and on the loan repayment program's eligibility and selection factors. These include that the applicant (1) has a history of honoring their prior legal obligations (i.e., is not in default on a federal loan, among other things); (2) does not have a negative report to the National Practitioner Data Bank, which records actions taken on individual's clinical licenses and malpractice judgements; (3) has not breached another health service obligation; and (4) does not have another current service obligation.¹²

Federal Scholarship Program

The NHSC Scholarship Program is established in Section 338A of the Public Health Service Act (PHSA).¹³ It provides scholarships—including tuition, reasonable educational costs, and a monthly living stipend—to individuals enrolled full-time in specified education programs at a fully accredited U.S. school.¹⁴ Eligible schools/programs include medical schools (allopathic and osteopathic), physician assistant programs, dental schools, and advance practice nursing schools. Individuals must agree to complete their training (including residency training or required clinical hours, where applicable) in primary care.¹⁵ For each year of scholarship support received (or partial year after the first year), students must agree to provide a year of service in a HPSA. For example, if a full-time service scholar receives three years of scholarship support the scholar would owe three years of full-time service at an approved facility. Scholars incur a minimum service commitment of two years. The number of school years of NHSC scholarship support received by the scholar may not exceed four school years.¹⁶ As such, through the scholarship program, the maximum required years of full-time service at an approved facility is four years.

NHSC scholars begin their service commitment upon the completion of training, including any advance clinical training needed for licensure (e.g., primary care residency for physicians). Participants must also have obtained a professional license, certificate, or registration before beginning their service commitment. NHSC scholars must fulfill their service commitment on a full-time basis and are required to fulfill their service commitment in a HPSA of greatest need. Each year HRSA determines the HPSA score indicative of greatest need. This varies by provider type. For example, for class year 2025, NHSC scholars must work at NHSC-approved service sites with a HPSA score of 19 or above for primary care physicians or nurse practitioners, 5 or above for primary care physician assistants, and 16 or above for nurse midwives. Scores also vary for mental health HPSAs and dental HPSA providers.¹⁷ Individuals participating in the federal loan repayment program may serve part-time and may serve in areas with lower HPSA scores, but scholars may not. At the end of their service commitment, scholars may apply for continuation awards through the loan repayment program if they still have educational debt remaining and are willing to continue service at an NHSC-approved facility. Generally, NHSC awards are made competitively, with scholarships awarded based on a set of eligibility and selection factors (e.g., the participant's commitment to primary care practice and the likelihood of remaining in a shortage area after the NHSC service commitment has ended).¹⁸ In HRSA's 2019 report on NHSC to Congress, the agency disclosed that there were more than 1,800 scholarship applications for the 200 awards made.¹⁹ The selection rate decreased since then, as HRSA reported that in FY2024 it was able to award 5% of eligible scholarship applications.²⁰

Federal Loan Repayment Program

The NHSC Federal Loan Repayment Program is authorized in PHSA Sections 331(i) and 338B.²¹ In addition to the list of providers who may participate in the scholarship program, dental hygienists and behavioral/mental health providers may also receive loan repayment.²² Loan repayment recipients must have a license or certificate needed to practice and must be employed or have accepted an offer to be employed at an NHSC-approved work site. Loan repayment is available only for qualifying educational debt, which means principal, interest, and related expenses of outstanding government and private student loans obtained for undergraduate or graduate education for tuition, along with reasonable educational and living expenses.²³ The section below discusses the main federal loan repayment program and additional specific loan repayment programs.

Main Loan Repayment Program

The main federal loan repayment program provides up to $75,000 for an initial two-year obligation for primary care providers assigned to a primary care HPSA and $50,000 for an initial two-year commitment for behavioral health and oral health providers working in mental health and dental health HPSAs, respectively.²⁴ Participants in the federal loan repayment program have a two-year service commitment, which they may fulfill full-time for two years or part-time for four. Continuation awards are awarded in one-year intervals, and individuals may apply for and receive continuation awards as long as they have qualifying educational debt and remain employed at an NHSC-approved site.

Federal Students to Service (S2S) Loan Repayment Program

In 2012, HRSA used the authority in PHSA Section 338B²⁵ to establish a new program within the federal loan repayment program called the Students to Service (S2S) Loan Repayment Program. The S2S program provides assistance of up to $120,000 to providers in their last year of training. At its outset, this program was for medical students (allopathic and osteopathic) in their final year of medical school; however, the program has since expanded to include individuals in their last year of dental school, nurse practitioner training, nurse midwifery training, and physician assistant training. In return, S2S program recipients must complete an approved primary care residency (if applicable)²⁶ and undertake their required NHSC service in a HPSA of greatest need for at least three years (full-time) or six years (half-time).²⁷ S2S repayors may also complete certain fellowships that may be one or two years. These include one-year fellowships in geriatrics or obstetrics/gynecology, two-year child psychiatry fellowships, and one or two-year addiction medicine fellowships.²⁸ The FY2025 application cycle also included a supplemental award for providers in Maternity Care Target Areas (MCTAs; see text box below). Physicians in MCTAs who practice obstetrics/gynecology, family medicine physicians who practice obstetrics, and certified nurse midwives may receive a supplemental award of up to $40,000 if they agree to serve in a MCTA with a score of 16 or higher.²⁹

Substance Use Disorder Repayment Program

Beginning in FY2018, HRSA received discretionary funding to provide loan repayments to behavioral health professionals who are providing substance use disorder treatment (SUD) in HPSAs. Language included in appropriations acts waives parts of the NHSC statute, which therefore permits a broader range of health professionals and service sites to be included in the program.³⁰ This program is not permanently authorized in statute; as such, it may continue only if similar language is included in annual (or supplemental) appropriations laws.

The program's purpose is to expand evidence-based SUD treatment and counseling available in HPSAs. Under this program, HRSA makes loan repayment to behavioral health providers, some of whom are not otherwise eligible for the NHSC loan repayment program (e.g., pharmacists).³¹ It also permits program participants to fulfill their service commitment in behavioral health treatment sites. Generally, NHSC sites are primary care focused, and, as such, facilities that focus exclusively on substance use treatment, such as opioid use disorder treatment programs, would not otherwise be eligible to receive NHSC clinicians. The SUD workforce loan repayment program provides $75,000 in loan repayment in exchange for a three-year full-time service commitment in a designated mental health or primary medical care HPSA. It provides $37,500 in loan repayment for a three-year half-time service commitment.³²

Rural Community Loan Repayment Program

The Rural Community Loan Repayment program is similar to the SUD loan repayment program with regard to eligible providers and sites. Like that program, the Rural Community Loan Repayment program focuses on increasing access to substance abuse treatment in rural areas, including access to opioid use disorder treatment.³³ Since FY2018, the program has been funded using a portion of the discretionary appropriations provided for SUD loan repayment. This program provides $100,000 for a three-year full-time service commitment for SUD treatment providers in rural areas. It also provides $50,000 for half-time clinical practice.³⁴

State Loan Repayment Program

The state loan repayment program is authorized in PHSA Section 338I.³⁵ The program is similar to the Federal Loan Repayment Program, except that (1) it is a matching grant between the state and the NHSC,³⁶ (2) states may choose to expand or contract the types of clinicians who are eligible to participate in their program, and (3) states may require more than two years of service in exchange for loan repayment. For example, states have the option of addressing their unique workforce needs by making additional types of professionals eligible, such as registered nurses and pharmacists, although neither of these provider types are eligible to participate in the main federal loan repayment program. State loan repayors must provide care in a HPSA in exchange for their award, but states determine the approved service sites (i.e., facility types) for their programs. State loan repayment participants must also serve two years as an initial commitment, but states may require longer minimum service commitments or may vary the service commitment length by provider type. State loan repayment recipients may fulfill their service commitments on a full- or part-time basis.

NHSC Funding

The amount of total funds that the NHSC receives determines the number of awards that the program can make. Historically, the NHSC had been exclusively funded as part of HRSA's discretionary appropriation. However, that is no longer completely the case, as the program is now primarily funded by the mandatory Community Health Center Fund (CHCF).³⁷ The CHCF is time-limited. At its outset, it was an appropriation from FY2011 through FY2015, but it has been extended several times, most recently through September 30 2025 in the Full-Year Continuing Appropriations and Extensions Act, 2025 (P.L. 119-4).

The CHCF was intended to supplement NHSC appropriations. However, from FY2012 to FY2017, the CHCF entirely replaced the NHSC's discretionary appropriation. Beginning in FY2018, the program received discretionary appropriations again, though these funds have been appropriated for loan repayment SUD treatment providers with some funds reserved for loan repayment for providers placed at Indian Health Service (IHS) facilities. Though the NHSC has received discretionary appropriations in recent years, the CHCF represents more than 70% of the program's annual funding in FY2023. As discretionary appropriations are available only for loan repayment for SUD treatment providers, the CHCF is the only annual source of scholarship support and support for primary care and dental clinicians. The exception to this was in FY2021, when the American Rescue Plan Act of 2021 (P.L. 117-2) provided a one-time appropriation of $800 million that temporarily expanded the number of awards that the program was able to make.³⁸

Table 1 presents funding provided for the program between FY2011 and FY2023. Definitive funding amounts for the Community Health Center Fund are not available for FY2024; as such, the table does not include this funding. The FY2023 Consolidated Appropriations Act (P.L. 117-328) provided $125.6 million in discretionary funding for the NHSC to support loan repayment for SUD treatment providers and reserved $16 million of that amount to place providers in facilities funded by the IHS. The table also shows the percentage of funding that comes from discretionary and mandatory sources.

Program Size

NHSC program size is measured in three ways: (1) funding, discussed above; (2) recruitment, which is the number of awards in different categories; and (3) field strength, which is the number of NHSC clinicians currently fulfilling their service commitments. Recruitment in a given year is generally smaller than the program's field strength because the latter includes loan repayors who are currently fulfilling their service commitments, including those who are fulfilling a second year of their service commitment, and individuals who received scholarships or S2S agreements in earlier years who have completed their required training and are currently fulfilling their service commitments. The section below discusses recruitment and field strength.

Recruitment

From FY2011 through FY2023, the most recent year of final data available, the NHSC provided more than 91,000 loan repayment agreements and scholarship awards to individuals who have agreed to serve for a minimum of two years in a HPSA. The resumption of discretionary appropriations for loan repayments in FY2018 increased the number of loan repayment awards that the program was able to make.³⁹ Table 2 shows NHSC clinician recruitment activity for the NHSC's active programs, by type of award, from FY2011 through FY2023.

Field Strength

The number of awards the NHSC makes at any point in time is only one component of program size, as not all awardees are currently serving as NHSC providers. Specifically, NHSC scholars and S2S program participants are still completing their training. As such, the NHSC also measures its field strength, which is the number of NHSC providers who are fulfilling a service obligation in a HPSA in a given year.⁴⁰ In FY2023, total NHSC field strength was 18,335.⁴¹ Field strength is a measure of both the NHSC appropriation, which affects the number of awards that can be made, and the relative balance between scholarships and loan repayment, both in the current fiscal year and in the past.⁴² The NHSC field strength has increased in recent years as the number of awards made has increased (see Figure 1). The majority of these individuals (14,450) were in the main loan repayment program, which reflects the NHSC's prioritization of clinicians who will undertake their service commitment immediately in HPSAs.⁴³ In contrast, HRSA makes scholarship awards in an earlier year, so the funding investment is not realized until after the scholars complete their schooling and required training.

Despite increased field strength, more sites are eligible to receive an NHSC provider than there are NHSC providers. Specifically, as of September 30, 2023, more than 21,000 sites were eligible for NHSC clinicians and the program's field strength was 18,335—meaning that the NHSC field strength, which is driven by the program's appropriation and its ability to make awards, was not sufficient to meet the needs of every eligible NHSC site.⁴⁴

Figure 1. Trends in National Health Service Corps (NHSC) Field Strength (FY2011-FY2023, by number of providers who are fulfilling a service obligation in a HPSA in a given year)

Source: Prepared by CRS, based on data in U.S. Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY2025 Rockville, MD, p. 93; U.S. Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY2022, p. 90; and U.S. Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY2018, p. 74. Note: NHSC field strength is the number of NHSC clinicians or providers who are fulfilling a service obligation in a Health Professional Shortage Area (HPSA) in exchange for a scholarship or loan repayment agreement. The increase in FY2022 represents clinicians receiving awards funded under the American Rescue Plan Act in FY2021.

Types of NHSC Providers

The NHSC is made up of an increasingly diverse set of health professionals. In FY2009, physicians accounted for nearly 35% of providers and were the largest group of providers in the NHSC. In contrast, in FY2016, they made up 21%, and behavioral/mental health providers had become the largest provider type at 30% of all providers in that year.⁴⁵ In FY2018, the SUD workforce loan repayment program began, further increasing the number and type of behavioral/mental health providers in the program. In FY2023, 48% of providers were behavioral/mental health providers.⁴⁶ Nurse practitioners (19%) and then physicians (14%) were the next largest groups of providers. Combined with behavioral/mental health providers, these three provider types made up 79% of the NHSC in 2023.

Figure 2 shows the NHSC's workforce by provider types in FY2023, the most recent year for which complete data are available.

Figure 2. National Health Service Corps (NHSC) Field Strength, by Discipline (September 2023)

Source: Prepared by CRS, based on data in U.S. Department of Health and Human Services, Health Resources and Services Administration, Justification of Estimations for Appropriations Committees, FY2025, Rockville, MD, p. 90. Notes: Total providers = 18,335. Physicians include both allopathic physicians who hold a Doctor of Medicine (MD) degree and osteopathic physicians who hold a Doctor of Osteopathic Medicine (DO) degree. "Other State Loan Repayment Clinicians" may include registered nurses and pharmacists, among others.

NHSC Provider Locations

NHSC providers may serve at a number of facility types that generally focus on providing outpatient primary care to patients regardless of their ability to pay. In addition, some NHSC provider sites generally focus on primary care, such as federal health centers, while others may target behavioral health, such as community mental health centers. As mentioned, these facilities must be located in HPSAs. NHSC eligible sites include⁴⁷

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

NHSC providers can be placed at facilities operated by not-for-profit organizations and by government entities (including state, local, tribal, and federally operated facilities). In addition, HRSA requires that NHSC sites are part of a system of care (e.g., have referral arrangements for specialty care and after-hours arrangements for patient care); have a documented record of sound fiscal management; have a history of using NHSC providers appropriately and efficiently; accept beneficiaries from Medicare, Medicaid, and CHIP; have a sliding scale discount schedule; and have general community support for assigning NHSC providers to the facility.⁴⁸

For the SUD Loan repayment program, HRSA made additional sites eligible. These include outpatient Opioid Treatment Programs (OTPs) certified by the Substance Abuse and Mental Health Services Administration (SAMHSA)⁴⁹ and office-based opioid treatment facilities (OBOTs).⁵⁰

More than half of all NHSC providers serve at federally qualified health centers (FQHCs), which provide outpatient—generally primary and behavioral—health care to disadvantaged populations regardless of patients' ability to pay.⁵¹ NHSC providers also increasingly provide care at facilities funded by the IHS, including federal, tribal, and urban Indian health facilities; this is particularly true with funds appropriated in FY2019-FY2023 to place NHSC providers at IHS-funded facilities.⁵² As mentioned, NHSC providers generally fulfill their service commitment in outpatient settings. However, some may serve at IHS-funded hospitals, and in recent years, some have fulfilled part of their service commitment (up to 24 hours per week) at critical access hospitals (CAHs), which are small hospitals located in rural areas. HRSA requires that these providers split their time between inpatient services at the CAH (up to 24 hours per week) and outpatient services at CAH affiliated-outpatient clinics (not less than 16 hours per week).⁵³

NHSC providers are located at HPSAs throughout the United States and its territories (see Figure 3). According to HRSA data from the end of FY2023, 39% of all NHSC providers served in rural areas.⁵⁴

Figure 3. National Health Service Corps (NHSC) Providers by State, Territory (FY2023)

Source: CRS Analysis of https://data.hrsa.gov/topics/health-workforce/field-strength. Note: FTE = Full Time Employee.

Provider Retention

The NHSC collects data on the retention of NHSC clinicians. HRSA modernized its data systems to better track its alumni starting in FY2019, which may provide additional insights into the program. In the FY2022 report on the NHSC, HRSA reported that 86% of those who had finished their service commitment in FY2020 remained in service in a HPSA. In addition, they found that 87% of those who had fulfilled their service commitments between 2012 and 2021 are either still working in a HPSA or remained in the community where they fulfilled their service commitment, even if it no longer qualified as a HPSA.⁵⁵

Legislative Proposals Related to the NHSC

This section discusses some common types of legislative proposals that would amend the NHSC and discusses how the new NHSC SUD loan repayment program (including the rural component) and a new separate loan repayment program for substance abuse providers interact with proposed legislation.

In general, legislative proposals for the NHSC have sought to expand the types of providers and service locations that are eligible for the program. For example, legislation in the 117^th Congress (H.R. 3759 and S. 2676) and 118^th Congress (H.R. 4829) would have made physical therapists eligible for the federal loan repayment program.⁵⁶ Legislation in the 118^th Congress (H.R. 9849) would have made medical laboratory personnel eligible for the program, and H.R. 6968 would have added marriage and family therapists as eligible for loan repayment. Although legislation has been used to modify the list of eligible disciplines, the HHS Secretary has some authority to add disciplines without new laws being enacted.⁵⁷ For example, in prior requests from appropriations committees about including pharmacists in the program, the HHS Secretary has declined to do so based on an interpretation that pharmacy and chiropractor services would be outside of the core intent of the NHSC to provide "primary health services."⁵⁸ Similar conversations have occurred between HHS and the House Appropriations Committee regarding optometry.⁵⁹ At present, pharmacists and marriage and family therapists are included in the SUD loan repayment program (including the rural component) and states can elect to include them in their loan repayment programs. Optometrists and clinical lab personnel are not eligible for the federal NHSC loan repayment programs.

In general, HHS has not agreed to expand the list of the main loan repayment program's eligible provider types out of concern that doing so would shift the program away from its traditional focus of providing primary care to underserved populations. HHS also emphasized that the program is currently competitive and that adding new eligible disciplines could redirect NHSC funds away from already identified clinical shortage areas (and thus potentially create new ones).⁶⁰ Another concern is that adding new provider types may limit the total number of individuals served by the NHSC, because the new provider types (e.g., physical therapists) generally serve a narrower subset of the population than do primary care providers.

Despite debates on expanding the clinicians eligible for the NHSC, Congress has at times clarified the range of eligible providers. For example, in 2016, the 21^st Century Cures Act (P.L. 114-255) clarified that adolescent and child psychiatrists are eligible to participate in the federal loan repayment program.⁶¹ Generally, the NHSC does not include subspecialists (which child and adolescent psychiatrists would be considered to be); as such, it was not clear that these providers were eligible. This law, however, did not expand the list of NHSC providers. Instead, it sought to clarify that, within the existing group of NHSC-eligible psychiatrists, those who specialize in child and adolescent psychiatry are eligible to participate in the NHSC.

Congress has also expanded the NHSC provider types through the SUD loan repayment program. The SUD loan repayment program was first enacted in the Consolidated Appropriations Act, 2018 (P.L. 115-141), and has received discretionary appropriations in subsequent years. This program expanded eligibility for the NHSC loan repayment program to substance use disorder counselors and pharmacists, among others. These laws also increased NHSC funding and specified that this funding must be used to support awards to substance use disorder providers. These specifications in the law increased the overall size of the NHSC and added provider types with these additional funds. Adding additional funding, and not drawing from the NHSC funding otherwise available, may have averted a number of the displacement concerns that HHS has noted in prior efforts to expand the NHSC (i.e., that new providers added to the program have not reduced the number of primary care providers participating the in the program).

Legislation has also sought to add additional types of facilities as sites eligible to receive NHSC providers.⁶² For example, H.R. 5157 in the 117^th Congress would have permitted primary care providers working through direct primary care practice (where a patient pays a fee to access the practice) as eligible for NHSC scholarships or loan repayment if the practice is located in a HPSA. In the 116^th Congress, H.R. 6979 would have added facilities operated by the Department of Veterans Affairs as eligible for NHSC clinicians. Adding addition facility types raises a number of the same displacement concerns as does adding additional provider types. Currently, the number of sites eligible for the NHSC exceeds the number of clinicians that the program can fund. Adding new site types could increase the number of sites with unfilled positions and could create more competition between sites for providers. For the VA example, the agency has its own scholarship and loan repayment programs to recruit and retain providers. Should VA facilities be added as eligible for the NHSC, there may be a need for coordination across these programs.⁶³

In addition to proposals to expand the scope of the NHSC program, some legislation has sought to create new demonstration programs within the NHSC. For example, H.R. 2130 and S. 924 in the 117^th Congress would have created a demonstration program that would provide loan repayment in exchange for a five-year service commitment in a rural HPSA. NHSC loan repayment is a two-year service commitment in exchange for a one-time payment amount. In contrast, this program would require a five-year commitment and would pay one-fifth of a clinician's loan balance in exchange for each year of service. Currently, the NHSC had a rural community loan repayment program as a component of the SUD loan repayment program in recent years. In addition, the NHSC does place providers in rural areas under the current program. Specifically, at the end of FY2023, HRSA reported that 39% of its clinicians served in rural areas. This percentage is higher than the overall size of the U.S. population that resides in rural areas (20%) but is lower than the percentage of HPSAs that are considered to be rural (approximately 60% of all HPSAs).⁶⁴ The model of a longer-term service commitment in exchange for a percentage of loan balance repaid (as opposed to a lump sum) has also been proposed in H.R. 1127 in the 119^th Congress (and H.R. 4285 in the 118^th Congress), which seeks to create longer service terms as a way of increasing provider stability in HPSAs.

A longer loan repayment term is part of a new loan repayment program that was included as part of the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (P.L. 115-271, the SUPPORT Act). Specifically, Section 7701 enacted a new loan repayment program that was set up in FY2021 called the Substance Use Disorder Treatment and Recovery Loan Repayment program (or STAR LRP).⁶⁵ This program provides one-sixth of a provider's loan repayment balance per year for a six-year full-time service commitment at a qualified facility, including a number of inpatient facilities that are not eligible sites for the NHSC.⁶⁶ This program made its first set of awards in 2021; as such, the first awardees are still fulfilling their service commitments. No publicly available assessments of this program are available.⁶⁷ As such, it is not yet known whether the six-year service commitment will be a barrier to recruitment or retention. This program also permits a broader set of facilities to be eligible as service sites (e.g., inpatient psychiatric treatment facilities). A longer loan repayment period may be challenging because it could increase participants defaulting on their service commitment. This new program may be a way of determining whether some of the proposed demonstration projects within the NHSC (e.g., longer loan repayment, additional providers, and additional sites) are feasible.

Some recent bills have also proposed to use NHSC clinicians as a way of augmenting the health workforce in emergencies. The Coronavirus Disease 2019 (COVID-19) pandemic raised issues related to health workforce availability. One option offered in the 117^th Congress, S. 54 (similar to S. 4055 in the 116^th Congress) would have established a demonstration program that would permit NHSC clinicians to be deployed in emergency circumstances as part of the National Disaster Medical System (NDMS) in exchange for additional loan repayment. The NDMS includes volunteer medical personnel who may be deployed temporarily, at a state's request, to respond to a disaster. The demonstration program would also have permitted NHSC alumni to participate in exchange for additional loan repayment. This bill would have provided additional funding for this purpose, removing concerns that it would reduce the number of awards that the NHSC could make. However, NHSC clinicians provide care in HPSAs, which by definition have a shortage of providers that the program seeks to ameliorate. Deploying active NHSC clinicians may create concerns about health care availability in HPSAs. The bill also included additional loan repayment for NHSC alumni, which may entail fewer concerns about provider availability in HPSAs.

Calvin C. DeSouza, CRS Geographic Information Specialist, prepared the map included in this report, and Brion Long, CRS Visual Information Specialist, prepared the graphics included in this report. Joe Angert, CRS Research Assistant, contributed to this report.

Footnotes