In this article, I review the legislative history of Title VII of the United States Public Health Service Act. I describe three periods of federal support for health professions training in medicine and dentistry.
Early Arguments for Federal Support for Health Professions Training
Downsizing capacity to achieve higher standards creates shortages
When Abraham Flexner conducted his research for the Carnegie Foundation's publication, Medical Education in the United States and Canada (1910),1 he visited 155 medical schools—147 in the United States and 8 in Canada. These figures represented a steady decline in the number of schools operating after the Civil War, most of them two-year proprietary schools, as efforts continued in the latter half of the 19th century to improve medical education. Between 1904 and 1915 alone, 92 schools closed or merged because of financial difficulty, bad publicity, and higher standards called for by faculties, national organizations, and state licensing bodies. By 1929, the number of medical schools in the United States stabilized at 76, with most operating four-year programs within larger university systems and using laboratories and hospitals to train students in the basic and clinical sciences.2–4 The dental profession undertook a similar initiative to upgrade its schools, closing many in the 1920s that failed to meet more rigorous standards, thus reducing significantly the nation's dental training capacity.5
The American population increased by more than 35 million, from 115 million to 151 million, between 1925 and 1950, provoking warnings that the production of physicians, dentists, and other health professionals was inadequate to meet the needs of an expanding citizenry.6,7 The dental profession opened nine U.S. schools in the 15 years after World War II and enlarged enrollments to twice the prewar levels. But, larger class sizes and modernized curricula severely strained the budgets of most dental schools, and the lack of federal investment stymied further efforts to increase capacity.5,6 Similarly, three U.S. medical schools opened between 1935 and 1952, and the total number of medical graduates increased from 5,101 to 6,080.2,6,8 In 1953, Dietrick and Berson published the results of their comprehensive survey of medical schools that revealed a steady expansion of their programs (including a 35% increase in the number of medical school graduates since 1930) that similarly was severely taxing the schools' finances, facilities, and faculties.9 The authors called for a national campaign to educate the public, legislators, and donors on the complexity of these institutions, also realizing that their cry for increased funding for medical schools could be interpreted as too narrowly focused as the country embraced priorities that included the space program, hospital construction, and the National Institutes of Health.2,8,9
The leadership of the Association of American Medical Colleges (AAMC) responded quickly to the data made public by Dietrick and Berson and the national call for more physicians. Ward Darley, AAMC executive director, warned of the need first to strengthen medical schools' finances. In 1957, the AAMC called for further increases in enrollment at existing schools with expansion of their facilities and faculties. It also urged universities in major cities without a medical school to establish one. Quietly and persistently, Darley lobbied the deans of existing medical schools to support legislation to underwrite these costs.2
Consistent findings and recommendations
A series of federal commissions and reports in the 1950s reinforced the urgency of the country's impending shortage of health professionals. The President's Commission on the Health Needs of the Nation, published in 1953, projected a shortage of all health professionals including 22,000 to 45,000 physicians and 17,000 to 34,000 dentists by 1960.6,7 This report was the first to call for a major federal investment in medical and dental school construction.2,6,7 Three reports followed: the Bayne–Jones Report of 1958, Bane Report of 1959, and Jones Report of 1960, all highlighting the need for government assistance to expand the nation's capacity in health professions training.2,5,10,11 All three reports recommended expanding the number of medical schools by at least 20 and dental schools by 22, and that the cost be shared with the federal government matching either state resources or private and industry philanthropy.5,10,11
The Bane Report of 1959 generated the greatest response, in part because it included data and tables linked to policy recommendations. It focused primarily on the need for more physicians, but it also addressed the shortage of dentists and called for a workforce study of other health professions. In 1959, in the United States, there were 235,000 doctors of medicine and 14,000 doctors of osteopathy for a U.S. population of 177 million people or 141 physicians per 100,000 persons. Just to maintain the current ratio of physicians to population, projected population increases coupled with known expansion plans for schools of medicine and osteopathy would still leave a deficit of 3,600 medical graduates by 1975.11 Although the country after World War II significantly expanded the number of hospitals with federal, state, and local funds under the federal Hospital Survey and Construction Act (Hill–Burton Program) and the medical research infrastructure of many medical schools under the Medical Research Facilities Construction Act, no similar investment had been made in medical and dental education generally.8,11 As research became a core activity of many schools across the country and at NIH, further attrition of physicians into science moved members of the Bane Committee to recommend construction of at least 20 to 24 new two-year and four-year medical schools, preferably with teaching hospitals. To maintain the current ratio of dentists to population, the Bane Report proposed enlarging existing dental schools and building 22 new schools, at a projected combined cost of $230 million.11
Wanting to make careers in the health professions accessible to youth from all socioeconomic backgrounds, the Bane Report also called for loan programs for medical, osteopathic, and dental students and scholarship programs for students-in-need. These were intended “to relieve some of the financial pressure on students of medicine [and dentistry], to give greater equality of opportunity to talented young people, to encourage young people to plan for a career in medicine [or dentistry] at an earlier age, and to assure an adequate supply of physicians [and dentists].…”11(p58)
The Jones Report of 1960 further argued the pending Health Research Facilities Construction Act should be amended to include construction of health education facilities and that funds be appropriated at $60 million a year for the next 10 years to support the federal share of a long-range program of renovation, expansion, and new construction of schools of medicine, dentistry, and public health.5
Federal assistance for health professions training occurred in three phases. Period one, from 1963 to 1975, provided federal funds to expand the capacity of health professions schools to increase the overall number of physicians and dentists and, later, physician assistants (PAs) as well as optometrists, podiatrists, veterinary doctors, pharmacists, professionals of public health, and nurses. Period two, from 1976 to 1991, focused federal funds specifically on increasing the number of primary care physicians, dentists, and PAs trained in the United States, and diversifying the health care professions. Period three, from 1992 to the present, redirected health professions training programs in medicine and dentistry to new goals: (1) improving the quality of primary care education through innovation and national initiatives, (2) enhancing the training of primary care clinicians to care for vulnerable and disadvantaged populations in medically underserved communities (MUCs), and (3) increasing the diversity of the health professions, often through preferences and priorities specified in the grant guidance and incorporated into peer review criteria.
Period One: Building Capacity Through Construction, Renovation, and Expansion
1963: Landmark legislation
The Health Professions Educational Assistance Act of 1963 (Public Law [PL] 88-129) was the landmark legislation amending Title VII of the United States Public Health Service Act to authorize, for the first time, federal funding for the training of physicians, dentists, and other health professions personnel. The priority was to train more physicians and dentists, with recommendations that the number of medical school graduates be increased by 50% by 1975, and the output of dental schools doubled.
During hearings on the proposed legislation, the fate of the general practitioner—a role filled by family physicians, internists, and pediatricians—was noted as an area of concern. The continual loss of general practitioners from the workforce had reduced the ratio of one family physician per 1,300 persons in 1950, to one per 1,700 persons in 1960, with projections of only one general practitioner for every 2000 persons by 1975.12 Additionally, many states had no medical school and relied on others to produce the health professionals they needed, but had no mechanism to recruit them. As such, it was estimated there were 145 physicians per 100,000 population in metropolitan areas, but only 46 physicians per 100,000 population in rural counties.12 The third major problem was the need to recruit students from diverse socioeconomic backgrounds and to help students, particularly those from low-income families, finance their education. The data were clear: college students were choosing careers in the biological sciences, not medicine or dentistry, because of access to more than 10,000 federally funded fellowships and the expanding job opportunities in research after they finished their training.12
In response to these problems, the two major programs in the Health Professions Educational Assistance Act of 1963 were matching grants for construction of new health professions training schools and grants to fund loan programs for students. Congress authorized appropriations totaling $175 million ($25 million for fiscal year [FY] 1964; $75 million for both FY1965 and FY1966) to construct teaching facilities for schools of medicine, dentistry, osteopathy, public health, optometry, pharmacy, podiatry, and nursing (with $35 million for dentistry, $105 million for other health professions training schools, and $35 million for renovation of schools representing all the above disciplines). A total of $30.7 million was approved for loans to students of medicine, osteopathy, and dentistry. Schools receiving construction funds were required to increase their first-year enrollment by at least 5% and to maintain the increased enrollment for at least 10 years.12
1965: More construction and loans along with “basic improvement grants”
The Health Professions Educational Assistance Amendments of 1965 (PL 89-290) continued both the construction and loan programs. With $71.2 million in federal support, 18 medical schools had expanded their class sizes, and 6 new schools opened, adding 725 new places; with $33.6 million, 13 dental schools enlarged their enrollments, and 1 new school opened, adding 372 new places. The 1965 legislation authorized $480 million for new construction grants for FY1966 through FY1969, with medicine receiving $300 million and dentistry receiving $120 million. The goal was to expand capacity, with 2,000 more first-year places in allopathic and osteopathic medical schools and 1,200 more in dental schools (and a total of 6,000 new graduates in medicine, dentistry, public health, pharmacy, optometry, and podiatry). Congress also authorized appropriations of $25 million each year for the loan program, with students now able to borrow $2,500 per year. Up to 50% of the loan could be cancelled for work in a health professions shortage area (HPSA).13
The legislation authorized a new four-year program where schools of medicine, osteopathy, dentistry, optometry, and podiatry could apply for a “basic improvement grant” of $12,500 per school plus $250 per full-time student. In the second and subsequent years, schools would receive $25,000 plus $500 per full-time student. In return, a school had to increase its first-year class size by 2.5% or five students, whichever was greater. Schools receiving “basic improvement grants” would have preference for additional aid under the “special project grants” category, both designed to enhance the quality of education and relieve financial pressures created by new course offerings for students, faculty development activities, and continuing education programs for practicing physicians ($20 million for FY1966; $40 million for FY1967; $60 million for FY1968; $80 million for FY1969).13
By 1965, the health professions fully embraced federal intervention, with testimony submitted by every major medical, osteopathic, and dental organization as well as those representing hospitals, pharmacists, nurses, and public health professionals.13 In their State of the Union Addresses, both President John F. Kennedy in 1963, and President Lyndon B. Johnson in 1965, emphasized the need to fund health professions training. The launching of Medicare and Medicaid in the summer of 1966 gave 25 million Americans (the elderly, poor, and minorities) greatly expanded access to medical and hospital services. President Johnson used these data to argue for increased funding for health professions schools knowing that improved access would create the demand for more physicians and dentists. And, the requirement under both Hill–Burton and Medicare that training programs and health professions schools racially integrate and admit minority students in order to receive federal funding made health careers possible for hundreds of persons that previously had been denied admission because of race and ethnicity.14–16
1968: Sustaining and strengthening five health professions training programs
The Health Manpower Act of 1968 (PL 90-490) was designed “to sustain the Federal commitment to alleviate critical shortages of professional health personnel” and “strengthen five major health programs” that supported training of physicians, dentists, podiatrists, veterinary doctors, optometrists, pharmacists, public health professionals, nurses, allied health professionals, and research scientists.17(p3379) Even with increased enrollments at existing medical and dental schools and new schools scheduled to open, the country faced a projected shortage of 42,000 physicians and 12,000 dentists by 1973.17 A backlog of approved but unfunded construction projects served to further justify the program. Accordingly, Congress authorized $170 million for FY1970 and $225 million for FY1971, with the government matching local construction dollars two to one.
Much remained the same, with the student loan and scholarship programs and “institutional grants” replacing “basic improvement grants.” Already, 172 schools had received basic improvement grants to support teaching faculty, develop new curricula and teaching methods, and improve library resources.17 Schools of medicine, osteopathy, dentistry, optometry, and podiatry now were eligible to receive base grants of $25,000 plus $500 per full-time student and, in return, had to increase their class sizes. A new, separate, “special project” grants program was designed to assist schools in seven areas, including financial assistance.17 Inflation, along with greater demand for research equipment and educational technologies, pushed many schools to the edge of economic disaster. Congress authorized appropriations for these two programs ($117 million for FY1970; $168 million for FY1971) for institutional grants and special project grants together, thus rescuing again the operating budgets of many health professions schools.17 Of the $54.3 million obligated for special project grants in FY1970, $38.6 million was awarded for financial distress grants to 109 schools, including 60 of the 102 medical schools and 30 of the 51 dental schools.18
Two national commissions reinforced the previous pattern of congressional funding for infrastructure, curriculum innovation, and loans and scholarships to students. The Coggeshall Report in 1965, financed by the Commonwealth Foundation, analyzed trends in health care and their implication for medical education. Five years later, the Carnegie Commission on Higher Education published its report, Higher Education and the Nation's Health: Policies for Medical and Dental Education, that opened with data showing a lower health status for Americans. Like the Flexner Report 60 years earlier, Higher Education and the Nation's Health cemented the direction of reform for health professions training for the next 30 years. Similar to other national groups, the Carnegie Commission called for an increase in the number of graduating medical and dental students (by 50% and 20%, respectively), but now with attention to recruiting more women and minorities into medicine and dentistry. Other recommendations included loan and scholarship programs for medical students, capitation grants for instructional costs, and fiscal incentives for experiments in curriculum reform. Construction of university health science centers, coupled with implementation of innovative educational models at both the undergraduate and graduate levels, were envisioned to transform health professions schools into a national resource for solving larger public health problems and addressing the health needs of increasing populations. Two innovations, Area Health Education Centers (AHECs) and a National Health Service Corps (NHSC), were proposed as specific mechanisms to expand health care into the rural and underserved communities. Before closing, the Carnegie Commission forecast the creation of a National Health Manpower Commission charged to study the changing patterns of use of health manpower, with particular reference to development of new types of allied health personnel, including physician and dentist associates and assistants.2,19
1971: Stabilizing school finances and introducing federal support for primary care
Congress moved to put health professions schools on a firm financial base with passage of the Comprehensive Health Manpower Training Act of 1971 (PL 92-157).18,20 This legislation continued nearly all of the programs in previous acts; however, it changed “institutional grants” to “capitation grants,” still designed to alleviate the financial distress of schools ($200 million in FY1972; $213 million in FY1973; $238 million in FY1974), again with the requirement to expand class size by 5% or 10 students, whichever was greater.20 The student loan program ($50 million in FY1972; $55 million in FY1973; $60 million in FY1974) now allowed students to borrow $3,500 a year and pay back 85% of the loan in exchange for three years of work in an HPSA. For the first time, PL 92-157 included support for training programs for family physicians and PAs, two disciplines that continue to be included in Title VII legislation today. Family medicine training programs could apply for grants to train students, residents, fellows, and faculty, as well as community practitioners ($25 million in FY1972; $35 million in FY1973; $40 million in FY1974). PA training programs were eligible to receive grant awards to train students and faculty.20
Future trends predicted the demand for health services would continue to grow because of several factors: projected population increases of up to 27 million between 1970 and 1980, rising consumer incomes, expanding health insurance coverage, developments of medical science and the growth of specialization, and public policies designed to improve Americans' health by further extending medical care and hospital services to the elderly, poor, and minority populations. At the same time, the impact of specialization was beginning to be felt, with a drop in the ratio of family physicians from 101 per 100,000 population in 1931 to 28 in 1970.20 To fill the gap, this country was relying on graduates of foreign medical schools (FMGs), such that one of every four physicians licensed to practice medicine in 1970 had not graduated from a U.S. medical school.20
Accomplishments of period one, 1963–1975
Since passage of the original Title VII legislation in 1963, 164 health professions schools had received $791 million for construction of teaching facilities, resulting in 26 new schools and the expansion, renovation, or remodeling of 138 existing schools. Approximately 6,000 new first-year places were attributable to this construction. Additionally, more than 11,700 places had been maintained through renovation and replacement of obsolete facilities, with 5,876 of them in schools of medicine and 2,400 in schools of dentistry.20 If renovation and construction continued as authorized under PL 92-157 ($225 million for FY1972; $250 million for FY1973; $275 million for FY1974), the production of physicians and dentists could reach sufficient levels to alleviate projected shortages by 1978. A backlog of 100 approved but unfunded projects again motivated Congress to act (in part, because 46 of the projects had local matching funds to begin construction immediately).20 The legislation also allowed the federal contribution to cover up to 80% of the cost of new construction.
The 1971 legislation also addressed an impending crisis in the number of general practitioners and continuing problems with geographic maldistribution of physicians. Mechanisms included AHECs designed to expose students to clinical practice in rural areas through community-based clinical rotations, PA training programs to augment physician productivity (especially in rural settings), training of family physicians, and graduate education of physicians and dentists in primary care.
During period one, health professions legislation focused on ensuring the financial stability of schools and expanding their enrollments in response to concerns that the number of physicians and dentists—along with other health professionals—was inadequate to meet America's health care needs. These legislative efforts were tremendously successful. The effectiveness of capitation grants alone in combating financial instability was demonstrated by an abrupt decline in applications for financial distress grants after the 1971 act.18(p4957)
At the same time, the number of graduating students continued to climb. Between 1964 and 1974, graduates in medicine jumped 60% from 8,772 to 14,034; 83% in osteopathy from 441 to 808; and 44% in dentistry from 3,770 to 5,445.18 For medicine alone, 40 new schools opened between 1960 and 1980 (increasing the number from 86 to 126), with state governments contributing significantly to the costs of construction. In 1980, there were 15,677 medical school graduates, resulting in an increase in physician to population ratios of one doctor for every 515 persons in 1980 from one doctor to 754 persons in 1960.2 What persisted was geographic maldistribution of physicians and dentists, and the growing concentration of doctors in subspecialty medical practice. By the end of period one, support for training a primary care workforce had become one element of health professions legislation, but it was to become the centerpiece in period two.
Period Two: Building the Primary Care Infrastructure and Workforce in the United States
1976: Landmark legislation for primary care medicine and dentistry
On June 30, 1974, authority for five separate health professions training bills expired.18 As before, further federal support would require new legislation, and, thus, hearings on extending the Health Manpower Training Act began in the spring of 1974. Unlike the past, however, it would be more than two years, with 8,600 pages of public records generated from two sets of hearings in both the House and Senate, before new legislation was enacted.21
“Title VII, Section 747,” as it is generally known today, with its emphasis on primary care training in medicine and dentistry and care of underserved populations, emerged from the House–Senate Conference Committee with passage of the Health Professions Educational Assistance Act of 1976 (PL 94-484) by both houses of Congress in September 1976. This legislation defined, for the first time, primary care as family medicine, general internal medicine, general pediatrics, and obstetrics–gynecology.21
Debate and dialogue in hearings and committee meetings demonstrated widespread recognition of nine synergistic problems, six related directly to medicine and dentistry. These problems were (1) a persistent shortage of primary care physicians and dentists, (2) overconcentration of physicians and dentists in urban areas, (3) predominance of hospital-based training with a disproportionate increase in specialty training among physicians, (4) less-than-adequate preparation of the FMGs who were filling U.S. residency positions and staying in this country to practice, (5) the need for more PAs and dental auxiliaries to increase the productivity of doctors and dentists, and (6) too few students from minorities and disadvantaged backgrounds in all the health professions.18,21 Congress hoped the 1976 act would address all of these problems, but most agreed the legislation in itself could not solve the problems of geographic and specialty maldistribution. Neither could it stop the flow of FMGs, given the relaxation of immigration laws and expansion of residency positions as the number and size of hospitals throughout the country continued to grow.18,21
Consequently, PL 94-484 was a fundamental redesign of federal support for health professions training. Gone were appropriations for construction of new schools. Authorizing $40 million each year for construction grants, the legislation mandated that 50% be spent on ambulatory, primary care teaching facilities.18,21 Instead of large sums going to unrestricted scholarships and loans for students, Congress created the guaranteed student loan program, capping the amount a student could borrow at $50,000, with deferral of repayment for three years. Some scholarship support still existed, but only for students with exceptional financial need. One significant change—in keeping with the goals of this legislation—was a dramatic expansion of the NHSC, first established in 1972 to address geographic maldistribution of health professionals, particularly physicians, as well as to provide health care to medically underserved populations in both rural and urban areas.18,21
Capitation grants now required medical schools to limit the number of specialty residency positions. To be eligible for capitation funding, a school had to guarantee that the percent of residents trained in primary care (family medicine, general internal medicine, and general pediatrics) would increase from 35% in 1978, to at least 50% by 1980, while also expanding total enrollment by 10% or 10 students, whichever was greater.18,21 In addition, the House bill stipulated that every medical student had to spend at least six weeks in a remote setting, learning from a general practitioner linked to the medical school. The 1976 act expanded this requirement for osteopathic medical schools receiving capitation funding, mandating that they implement a six-week, community-based clinical rotation for all students. Dental schools had the option of rotating students in underserved rural and urban communities or dedicating a percentage of their residency training positions for general dentistry training.18,21
With the goal of training more primary care clinicians and exposing students to rural and underserved populations, Congress authorized appropriations for federal assistance for family medicine up to $170 million (both establishment and residency training grants); for general internal medicine residency and general pediatrics residency training, $35 million; for PA and dental auxiliary training, $90 million; and, for AHECs, $90 million18 (Table 1). With $385 million going to health professions training, and millions more authorized for the NHSC, guaranteed student loans, and construction grants to build ambulatory facilities, many believed the impending primary care workforce crisis could be alleviated.
1981: Expanding the portfolio of primary care training programs
The next major change in Title VII came with the Omnibus Budget Reconciliation Act of 1981 (PL 97-35) that allowed federal funds to be spent for residency training, faculty development, and fellowship training in both general internal medicine and general pediatrics ($17 million in FY1982; $18 million in FY1983; $20 million in FY1984).22 Previous authority for medical student and resident education, and faculty development in family medicine, was continued. The family medicine authorization was linked again to support for residency training in general dentistry, with total appropriations to both disciplines totaling $32 million in FY1982, $34 million in FY1983, and $35 million in FY1984. Establishment grants for departments of family medicine continued ($10 million in FY1982; $10.5 million in 1983; $11 million in FY1984), as did funding for the AHEC program ($21 million in FY1982; $22.5 million in FY1983; $24 million in FY1984). The AHEC dollars would be directed solely to allopathic and osteopathic schools of medicine, in part, to push clinical education of students and residents into outlying and rural areas. PA training would continue at a lower level of federal funding ($5 million, $5.5 million, and $6 million in FY1982, FY1983, and FY1984).22
With the new focus on primary care, general capitation funding was eliminated, and only $10 million approved for distress grants was now available to schools in long-term financial difficulty.22 Construction and curriculum grants were available to move two-year schools to four-year degree-granting institutions, to implement recruitment and retention initiatives for minority and disadvantaged students, and to develop curricula targeted at HPSAs, ambulatory clinics, and senior centers. Lastly, the secretary was charged to prepare several reports to Congress: one that analyzed factors influencing the career decisions of students, one on the status of health personnel in various professions, and one on the implications of the increase in the supply of physicians in various specialties.22
The Graduate Medical Education National Advisory Committee's report, published in 1980, with projections of a surplus of 150,000 physicians by 2000, fundamentally changed the administration's position.23 No longer would the president recommend annual appropriations for training health professionals or dollars to expand schools and clinics. The federal Council on Graduate Medical Education (COGME) released its first report eight years later, again predicting physician surpluses. The only discipline thought to be in short supply was family medicine.24 COGME did recommend that medical students be encouraged to enter primary care and that medical schools recruit more minority students. Geographic maldistribution persisted, with too few physicians in rural and inner-city areas.
Congress, however, interpreted the country's needs differently and continued to invest in health professions training in primary care. From the 1960s to the present, it emphasized as a goal of federal support the need to train health professionals to meet the needs of America's underserved and vulnerable populations. What changed were the programs and strategies to achieve this goal, sometimes emphasizing growth of the NHSC, at other times emphasizing general financial loan and scholarship programs to offset debt in order to attract economically disadvantaged students into medicine and dentistry, and students into primary care and medically undeserved areas.
Consistently, beginning in 1976 through every reauthorization up to the present, the primary care disciplines of family medicine, general medicine, and general pediatrics received federal support to train residents, with PA programs receiving funding to train students with a focus on primary care, and dentistry receiving funding for training residents in general dentistry. Beginning in 1981, general internal medicine and general pediatrics obtained added authority to apply for funds to train fellows and faculty and, in 1992, to train medical students. Family medicine retained its access to federal support to train students, residents, and faculty as well as special funds to establish departments of family medicine. In 1985, Congress authorized a new program for dentistry, advanced education in general dentistry, thus shifting dental residency training from primarily community-hospital- or clinic-based internships to ones located in teaching hospitals and dental schools.25
1988: Minor changes in training with larger diversity and loan programs
Reauthorization of the Title VII programs with passage of the Health Professions Reauthorization Act of 1988 (PL 100-106) again directed federal funds, but at a lower level, into health professions training in primary care, with Congress authorizing appropriations of $109 million each year for FY1989, FY1990, and FY1991 (with $7 million for establishment grants in family medicine, $22 million for AHECs, $22 million for general internal medicine/general pediatrics, $40 million for family medicine training, $10 million for dentistry, and $8 million for PA training).24Priority would be given to grant applications in general internal medicine and general pediatrics that demonstrated coordination of curriculum development with departments of family medicine where such departments existed. As before, recruitment of minority and disadvantaged students emerged as an area of critical need. What differed were new programs that provided $100 million across three years for educational assistance to these students, several million for retention programs, and, again, $30 million each year for scholarships for financially needy students.24 With the dramatic hike in tuition costs in the 1980s, Congress was forced to increase loan guarantees for the Health Education Student Loan and the Health Professions Student Loan programs, both designed to help students meet these costs and to encourage those of disadvantaged backgrounds to enter the professions.
Accomplishments of period two, 1976–1991
Period two of federal support for health professions training was a success and, at the same time, a continuation of unsolved problems and priorities. Across all federal agencies, and as experienced within the Title VII health professions training programs, dollars authorized in legislation were not always following in Congress's annual appropriation of federal funds, as illustrated in Table 2 for the family medicine residency training category. Nevertheless, between 1976 and 1991, general internal medicine and general pediatrics became academic divisions in departments of medicine and departments of pediatrics in most medical schools, and many schools developed primary care residencies.26–30 (Table 3) In 1991, departments of family medicine existed in 99 allopathic medical schools and in all but one osteopathic medical school.31,32 That same year, there were 390 family medicine residencies in both teaching and community hospitals. On average, 44% of Title VII grant applications for residency training in family medicine had been approved and funded since the program was started in 1971–1972.33,34 Between 1978 and 1993, more than $73 million was awarded to fund family medicine faculty development programs that had provided training to roughly 30,300 individuals.35 In addition, dentistry had received 51 grants to establish new programs, 106 to expand, and 19 to improve existing programs, with almost two thirds of the funding going to general dental residency training.25,36 New PA programs were opening yearly with graduates joining primary care physicians, thus improving their clinical productivity and increasing access to medical care in rural and underserved areas.37,38 What persisted were the lack of programs that successfully placed graduates into medically underserved areas and the absence of schools and programs that recruited a significant percentage of minority and disadvantaged students (and faculty) into the health professions.
Period Three: Refocusing on Care of the Vulnerable and Medically Underserved
1992: Vulnerable populations, MUCs, and health professions diversity
The third period in federal support for health professions training began with reauthorization of Title VII under the Health Professions Education Extension Amendments of 1992 (PL 102-408). The new legislation sought “to place greatest emphasis upon activities that will improve health care access and delivery by increasing the training of health care providers most important to the provision of primary care services, particularly the medically underserved.”39(p1408) Strategies to achieve these policy goals included new grant scoring mechanisms, a new primary care loan program, maintenance of AHECs, funding for all of the primary care medicine and dentistry training programs, and federal support for diversity pipeline programs. A new primary care loan program was created for students who committed themselves to careers in family medicine, general internal medicine, general pediatrics, preventive medicine, and osteopathic medicine. In addition, scholarships for the exceptionally financially needy and for the disadvantaged were made available only to students who agreed to pursue residency training in a primary care medical discipline or in general dentistry.39
The primary care training programs became subject to two new grant scoring mechanisms—the “Primary Care Priority” and the “MUC Preference”—designed to reward departments and divisions that trained students and residents who pursued careers in primary care and/or who, as clinicians, provided the majority of their care to patients in MUCs (Sidebar 1). Although Congress clearly sought to define flexibly what constituted an MUC (Sidebar 2), the definition of an MUC has become more explicit during the past 15 years. Currently, the requirement to meet the MUC preference is 30% of medical students and 55% of residency training graduates in FY2008.40
Congress, in approving the 1992 act, demonstrated its belief that federal support for health professions training in primary care medicine and dentistry was necessary. To reverse the steady drop in the number of students entering family medicine, it was recommended that departments of family medicine be established at every medical school in the country. Accordingly, the legislation required 20% of the annual appropriation for family medicine (20% of $54 million each year for FY1993 to FY1995) be used for establishment grants, and the remaining amount for training programs for students, residents, fellows, and faculty.39
Similarly, beyond the residency training and faculty development program areas, general internal medicine and general pediatrics were granted new authority to create clerkships for medical students. As noted in hearings, “exposure of students to primary care role models in community or ambulatory settings, and clerkships or rotations in primary care [would] have a positive impact on their career choice, and selection of primary care residencies, and subsequently, on primary care specialty practice.”39(p1419) These two disciplines together were authorized to receive $25 million each year. Dentistry was authorized under a separate section at $6 million each year to support general dental residency training and advanced education in general dentistry residency training. The PA training program was authorized at $9 million, with 10% going to faculty development.
Support for AHECs at $25 million each year ensured the expansion of community-based clerkships for medical and dental students as well as residents in family medicine, general internal medicine, and general pediatrics. Stronger AHECs would emerge from this legislation, linking medical schools and dental schools with rural communities and their practitioners. Lastly, the critical need to diversify the profession emerged again, only this time a new program, the Disadvantaged Faculty Development Fellowship Program, was added to Centers of Excellence and the Health Careers Opportunity Program, Title VII's two major pipeline programs.39
As before, the legislation gave the federal government authority to issue contracts. The articles by Davis et al,41 Glicken,42 and Hedgecock and Steyer43 in this theme issue describe some of the outcomes of these contracts—all awarded to national organizations. Most significant, new models of ambulatory training were developed. Their implementation nationwide contributed to moving medical and dental education and residency training out of hospitals into community-based training sites, physicians' offices, and hospital-based ambulatory clinics, with experiences and exposure to rural and underserved populations.
1998: Consolidation, collaboration, and innovation
Title VII most recently was reauthorized under the Health Professions Education Partnerships Act of 1998 (PL 105-392).44 The 1998 act consolidated 44 different federal programs into one piece of legislation. Existing separate categorical authorities for support of Family Medicine Training (Section 747), General Internal Medicine and General Pediatrics Training (Section 748), General Practice of Dentistry (Section 749), and Physicians Assistants (Section 750) were replaced by a new, consolidated grant and contract authority with Family Medicine, General Internal Medicine/General Pediatrics, Physician Assistant, and Dentistry, all falling within Section 747. The program was renamed the Training in Primary Care Medicine and Dentistry grant program. When implementing the legislation, all of the disciplines came under a single grant guidance, with requirements to be applied across all program areas. Dentistry gained added authority to apply for grant funding to train residents in pediatric dentistry.25,36,44
Consolidation especially impacted the dental residency programs. PL 105-392 specified vulnerable populations to include persons with HIV/AIDS, victims of domestic violence, the elderly, homeless and substance abusers, and persons living in MUCs that included rural and urban settings with too few primary care clinicians and dentists per population in need. Dental residency training applicants now were subjected to the MUC preference and were required to apply for funding for curriculum innovations to train dentists on the dental needs of vulnerable populations as defined in the legislation.
Since 1998, all grant applicants, including PA training programs and dental residencies, have had to propose curricula targeting these vulnerable populations and at least one other area of special priority.30,32,36,38,44–50 The government has continued to have authority to issue contracts. These have enabled national organizations to advance innovative training models in ambulatory care, faculty development programs, and education in areas of relevance to 21st-century medicine.37,41–43
Title VII has contributed most directly to the recruitment of minorities in the health professions through its two major pipeline programs, Health Careers Opportunity Program (HCOP) and Centers of Excellence, and through the Training in Primary Care Medicine and Dentistry grant program (Title VII, Section 747). HCOP grantees are expected to take a “comprehensive approach” to the development of minority youth. All HCOP grantees must (1) recruit disadvantaged students, (2) facilitate entry of disadvantaged individuals into colleges and health professions training programs, (3) provide counseling, mentoring, and other services, (4) disseminate financial aid information, (5) expose students to primary care in public or private community-based facilities, and (6) partner with other institutions of higher education, school districts, and other community-based organizations. The partnership plan must include a health or allied health program, an undergraduate institution, school districts, and community-based organization(s). In addition to after-school and summer enrichment programs, students are to engage in activities that foster cultural competence.51
The Centers of Excellence program is designed to enhance diversity in the health professions. Each center must meet six legislative requirements: (1) creating a competitive applicant pool, (2) improving academic performance, (3) supporting faculty development to train, recruit, and retain underrepresented minority faculty, (4) addressing minority health issues in clinical training, curricula, and information resources, (5) supporting faculty and student research in minority health, and (6) providing community-based training in clinics serving larger numbers of minority patients. The Centers of Excellence are designed to focus on specified underrepresented minority groups and may have one of four designations: Historically Black Colleges and Universities, Hispanic Centers of Excellence, Native American Centers of Excellence, and “Other” Centers of Excellence, which must enroll underrepresented minorities at rates above the national average.51
These two pipeline programs, HCOP and Centers of Excellence, have the highest impact factors of nearly all of the grant programs administered by the Health Resources and Services Administration and, thus, have a proven track record of recruiting underrepresented minority students into health professions careers and retaining them once in medical school and on faculty. The Centers of Excellence have contributed innovative curricula and conducted important research on the problem of health disparities.
The Training in Primary Care Medicine and Dentistry grant program has achieved a higher rate of recruitment of minorities into training programs and on faculties of medical and dental schools. This has been achieved in part through the grant guidance that awards additional points in the peer review process to those applicants with formal mentoring and career development programs for minority trainees and a successful track record of minority recruitment and retention of faculty. Consequently, Title VII, Section 747 programs graduate two to five times more minority and disadvantaged students (medical, dental, or PA students, residents, or fellows) and have more minority faculty than do non-Title VII, Section 747 programs.52 As the paper by Green et al48 in this theme issue illustrates, Title VII-funded residency programs are more successful in teaching residents skills in cultural competency. Additionally, graduates of Title VII-funded programs are 3 to 10 times more likely to practice in an MUC.37,52
Summary and Overall Accomplishments, 1971–2008
In summary, federal support for health professions training has impacted all the health professions, not only those of medicine and dentistry. As described in many of the papers in this special theme issue, in the area of primary care curricula and training as well as the overall size of the primary care workforce and its infrastructure, the outcomes of Title VII are significant. By 2000, the number of family medicine residences had grown from 12 in 1969, when the discipline was first established, to more than 493, with at least one family medicine residency program in every state. Departments of family medicine existed in all osteopathic, and all but 10 allopathic medical schools, with family medicine student clerkships conducted in all but 20 schools. The number of PA training programs had grown from 12 in 1970 to 129 in 2000, all fully accredited. By 2000, there were 104 general internal medicine residencies nationwide. More than 16,000 general internists had trained in these primary care residencies during the previous 15 years, with more than two thirds of graduates continuing to practice general medicine. Similarly, general pediatrics as an academic and clinical area within pediatrics had become firmly established, with more than 119 divisions of general pediatrics throughout the country. Title VII funds had created 59 new general dentistry residency programs and 560 new training positions, for a net growth of 72% in programs and 77% in residency positions.37
The Title VII health professions training programs enabled the disciplines of dentistry, PA, family medicine, general internal medicine, and general pediatrics to remain vital to the education of students, residents, and fellows as medical schools spent more and more of their resources training subspecialists. They also have been effective in recruiting and retaining minority trainees and faculty and placing graduates into MUCs. The commentary by Rich and Mullan53 in this theme issue speaks to the impact that even these limited federal dollars for primary care training have had amidst the flood of funding to support the expansion of the specialty and subspecialty workforce in this country. The real story is that primary care survived at all.
As noted by several authors in this theme issue, the recent and dramatic cuts in Title VII funding were devastating both to the staff that administer the program and to the educators throughout the country who rely on these federal dollars to prepare America's future primary care medical and dental clinicians. Consequently, the program has lost much of its impact on maintaining and shaping the generalist workforce in this country. With the loss of generalists from medical and dental practice, enough to create a crisis, many believe the time has come for a major expansion of the Title VII primary care programs in medicine and dentistry in partnership with funding for loan and scholarship programs and diversity pipeline programs. The question is whether Congress will respond once again as it has done during the previous 40 years.
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