By Rose Hoban
Frank Diaz really likes his job.
He’s has been working as a dentist at Rosewood Dental Services, which is part of the Goshen Medical Center in Goldsboro for coming on two years.
The clinic serves a primarily rural population of low-income patients, many of whom live below the poverty line.
Diaz, 30, started there after finishing school at UNC Chapel Hill’s School of Dentistry in 2015. He was first exposed to the Rosewood clinic one summer during school.
“It really opened my eyes to really helping people out with their needs,” he said.
The patients in the chair reminded Diaz of himself when he was younger, one of a family of Mexican immigrants.
“We were very poor. We didn’t have Medicaid or anything like that,” he remembered. “So I went through a lot of dental problems when I was a little boy.”
Working in the clinic that summer sealed Diaz’ decision to work in that setting. “I felt like I could make a bigger impact… rather than just working in a private dental office or a chain clinic.”
What made it possible for him to take Goshen Medical Center’s lower salary was his acceptance into the National Health Service Corps, a 46-year-old federally funded program which will help pay Diaz’ $140,000 student loan debt. In four years of service in the clinic, the program will pay off $100,000.
“I didn’t hesitate,” he said. “If I didn’t have it, it’d be very difficult.”
But the NHSC has been in jeopardy this fall because Congress has not reauthorized funding for the program.
Temporary fixes
In late December, both the U.S. House of Representatives and the U.S. Senate voted on a “continuing resolution,” which is the technical term for a temporary extension of last year’s federal budget.
The CR, as it’s known on Capitol Hill, will fund the National Health Service Corps through March.
But the damage may already have been done.
Currently in North Carolina, there are 237 people receiving loan repayment from the NHSC. More than 100 of those people work in community health centers across the state. Some of those folks did not get their checks in November.
“It’s already a bit of a challenge to get providers, dentists, people who care for AIDS patients in our clinics,” said Pam Tripp, CEO of CommWell, a network of federally funded community health centers scattered across five southeastern North Carolina counties.
Tripp said she had seven or eight providers who were getting loan repayment from the NHSC and that two of them had not received their loan checks in November.
“They’ll have to go somewhere else where they can make the most bang for the buck, no matter if their heart is in working in rural health or not,” she said.
“I cannot hire a dentist full time without loan repayment,” said Katrina Mattison-Chalwe, the dental services director for Piedmont Health, which has 13 dentists scattered among its clinics in Orange, Chatham, Alamance and Caswell counties. Three of Mattison-Chalwe’s young dental hires were denied loan repayment this year, one after working full time for a year, based on the belief he’d receive help paying off his large debt.
“The benefits at a community health center are really good but the pay is not that great,” she said. “We offset that by saying you’re a new student out of school, you don’t have any experience, you can learn here with us and we’ll employ you and in addition you can get your loans paid back.”
This is the first time since 2011 that Mattison-Chalwe has not been able to guarantee the loan repayment for one of her employees.
According to Elaine Ellis from the North Carolina Medical Society, her organization has provided some stop-gap money. The society already has a different loan repayment program that supports about 40 nurse practitioners, physician assistants and physicians around the state. On top of that commitment, she said they were able to find funds help four or five people who are part of the NHSC and who did not get federal loan repayment checks in November.
“We don’t have unlimited funding,” she said. “This is in addition to the people already part of our program, this is something extra.”
Stalemate
Craig Kennedy, who runs the Washington, DC-based Association of Clinicians for the Underserved, has been calling Congress and talking to people on Capitol Hill about reauthorizing funds for the NHSC. While he was relieved by the CR that moved late last month to provide a temporary fix, he said clinic leaders can’t make workforce decisions based on month-to-month funding.
“[We’re] not happy that Congress can’t find a way to fund effective and bipartisan programs,” he texted to NC Health News. “We have been told all year by both sides not to worry, ‘We will fund you.’ Well, we are worried.”
[sponsor]In the fall, House Republicans introduced the Championing Healthy Kids Act, which would have reauthorized funding for both the NHSC and the nation’s community health centers. But the bill paid for the programs by slashing the Prevention and Public Health Fund, which was created by the Affordable Care Act. It also would reduce the time that people have to pay for their Affordable Care Act insurance premiums from 90 days to 30 days, creating a short-term windfall for federal coffers.
“That was the reason Democrats didn’t go for the Champions bill, the pay-fors were unreasonable,” said Ben Money, who heads the North Carolina Community Health Center Association. He expressed aggravation at the stalemate.
“Congress is letting the community health center program degrade unnecessarily by their delaying,” he said. “It’s squandering investments that’ve been made by both the Bush and Obama administrations.”
Retention
Research shows that the longer a rural practice can retain a provider, the better the chances that person will stick around for life, said Kennedy.
He worried that the uncertainty may have longer term ramifications for the rural and community health center workforce. He’s heard that people who had missed payments in November are particularly frustrated.
“Right now who wants to extend for another year?” he asked. “Say you were in western North Carolina and you’ve been there for two years and you want to extend your NHSC obligation for one more year. But the federal government is going to say we don’t have the money?”
He also worried that the political drama would deter students finishing up their training from applying for the program.
“People are really making lifetime decisions about where they want to serve,” he said. “But then they’ll say they don’t have confidence this is going to get resolved, and ‘I have to pay my loan, my loan payments are due every month.’
“Your medical school debt doesn’t go away while you wait for Congress to act.”
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