Despite spending more per capita on health care than any other nation, the United States lags behind other industrialized nations in all major health outcome measures. This is due to 2 main factors: (1) relative to the rest of the world, the United States places far less emphasis on public health and primary care, and (2) because socioeconomic disparity in the United States is high and one sixth of the people lack health insurance, the United States has a large medically vulnerable population.
Title VII of the Health Professions Education Assistance Act is the only federal program that has increased the production of primary care physicians who serve medically vulnerable populations.1 Yet each year over the past 2 decades both Republican and Democratic administrations have recommended drastic cuts for this program. Until this year, Congress has annually restored the major portion of the funding for Title VII. In 2006, however, Title VII was severely slashed. The Title VII Primary Care Medicine and Dentistry Cluster received a cut of 54%, from $88.8 million for FY2005 to $41 million for FY2006. This cut will have a significant impact on family medicine programs. No new grants will be awarded this year, existing 3-year programs will be funded at reduced levels, and many important programs that have relied on 3-year cycles may cease to exist.
Title VII grants have supported the development of innovative programs that have been generalized to the larger educational experiences of medical students and residents. They have, for example, spurred the development of curricula in community-oriented primary care and provided clinical training sites where physicians learn to serve vulnerable populations. More important, these grants are the foundation for programs that train academic leaders of the future who are more likely to instill in their students an understanding of the importance of personal medical homes and a sense of obligation to serve communities and populations.
A loss of federal funding for primary care and public health training programs will have a negative effect on the health of all Americans, but particularly for vulnerable populations. Who will be the doctors for rural Americans, for low-income and inner-city communities, for minority populations and for our burgeoning population of senior citizens?.
Federal policies answer these questions with an inherent irony, illustrated in a study of all federally funded Community Health Centers (CHCs) by Rosenblatt and colleagues and the associated editorial by Forest.2,3 From 2001 to 2005, the number of Americans in vulnerable populations served by community health centers rose 36%, from 10.3 to 14 million. In 2002, the Federal Healthcare Initiative became law, and established a $780 million plan to create new CHCs and expand existing CHCs. The initiative estimated that by 2007, 21 million Americans would be served by CHCs, thus expanding the true safety net of personal medical homes for medically vulnerable populations.
Rosenblatt found that 90% of the CHC physicians are primary care physicians, over one half of whom are family physicians, and that more than 400 family physicians are needed immediately to fill the vacancies in CHCs. Paradoxically, while the federal government has dramatically increased funding for new and expanded community health centers, it has drastically cut funding for programs like Title VII that train the health care providers who are needed in these vital personal medical homes. These policies will assure that the number of vacancies for primary health care providers will continue to rise and CHCs will struggle to meet the needs of their communities.
What should we do? We must petition our legislators with redoubled effort. We must parade our Title VII successes before them, and continue to provide the information and build the relationships that encourage them to make informed decisions. In particular, we should all vigorously support the following actions:
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Restore and increase funding to Title VII, Section 747, the Primary Care Medicine and Dentistry Cluster of the Health Professions Education Assistance Act, and support the reauthorization of an improved Title VII.
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Eliminate barriers that inhibit cooperative relationships between CHCs and family medicine training programs.
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Earmark a large proportion of GME payments from CMS to support generalist physician training programs.
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Develop stronger alliances with other primary health care providers, including general internists, general pediatricians, nurse-practitioners, physician assistants and others who together give a stronger voice for primary care.
The programs supported by Title VII, which have been on the cutting edge of medical education, are now on the cutting room floor of a misguided federal healthcare plan. Supporting Title VII programs must be a priority in our efforts to reduce health disparities.
- © 2006 Annals of Family Medicine, Inc.
